A Qualitative Exploration of Community Health Workers’ Roles and Motivations in Delivering Care During and After the COVID-19 Pandemic: Experiences and Community Perceptions in Rural and Urban Delhi, India

A Qualitative Exploration of Community Health Workers’ Roles and Motivations in Delivering Care During and After the COVID-19 Pandemic: Experiences and Community Perceptions in Rural and Urban Delhi, India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Exploration of Community Health Workers’ Roles and Motivations in Delivering Care During and After the COVID-19 Pandemic: Experiences and Community Perceptions in Rural and Urban Delhi, India Audrey Steenbeek, Seema Rani, Noah Doucette, Fareha Khan, Shilpi Sarkar, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9141682/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: This study examines the experiences of community health workers (CHWs) providing care in Delhi India during and after the COVID-19 pandemic, and how their roles were perceived and accepted by beneficiaries and community leaders. Although CHWs are critical to healthcare delivery, limited evidence describes how they navigate role expectations, community dynamics, and system complexities to better improve health outcomes. Methods: A qualitative descriptive study using semi-structured interviews and field observations with 12 CHWs, five community members, and four community leaders (March–May 2025). The Lévesque conceptual framework guided data collection and analysis. Data were analyzed using content analysis. Results: Across the supply-side domains (approachability, acceptability, availability/accommodation, affordability, and appropriateness), three key categories emerged: (1) trust and respect, (2) professional values, and (3) norms, culture, and family. For the demand-side domains (ability to perceive, seek, reach, pay, and engage), one key category, community needs was identified. COVID-19 impacts and quality-of-care concerns were evident across all domains. Conclusions: Findings highlight the need for future research on sociocultural influences shaping CHWs’ professional roles, the sustainability of incentive-based remuneration, and the long-term implications of digital technologies adopted during crises such as COVID-19. Community Health Workers healthcare service delivery Lévesque conceptual framework health outcomes qualitative descriptive research BACKGROUND Healthcare systems are often strained by workforce and resource shortages, and although these challenges are not new, the COVID-19 pandemic exacerbated the strain on healthcare worldwide, prompting innovative approaches to healthcare delivery. 1 In many low to middle income countries like India, these shortages predated the pandemic and historically, hindered equitable access to healthcare. 2 The integration of community health workers (CHWs) into healthcare systems has evolved as a strategy to enhance equitable access and quality of care. 3 , 4 CHWs, also known as health navigators or health promoters among others, 5 are trusted community members with targeted training to deliver a range of services. Their position within their communities enables them to bridge formal healthcare systems with the populations they serve, mitigating persistent health inequities. 4 , 6 Evidence demonstrates, that when CHWs are integrated into existing healthcare systems they improve health outcomes, including disease prevention (e.g., vaccination), 1,3 enhanced patient-provider communication and trust, 1,3,7 treatment adherence, 1,4,7 and linkage to health and social services. 1 , 3 , 7 They also support the management of chronic diseases like diabetes and hypertension, 4 facilitate cancer screening, 4 and improve maternal and child outcomes. 3 , 6 In India, CHWs or Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and Auxiliary Nurse Midwives (ANMs), are central to the success of community-based health initiatives. 6 They help provide family planning/contraception, conduct home visits, promote maternal and child health, and collect census data, while promoting public health awareness. 6 Their strengths lies in their ability to establish interpersonal relationships grounded in their community’s cultural understanding, trust, and shared experience. By prioritizing these social bonds, CHWs in India, have effectively tailored healthcare to local contexts, accounting for language, norms, and community values. 1 During the COVID-19 pandemic, many CHWs also helped address misinformation and fear surrounding the virus by providing timely and accurate information to their communities about transmission and precautions including vaccination, quarantine, testing and masks. 1 , 8 , 9 Through these efforts, CHWs have become indispensable to the delivery of equitable and culturally responsive care in India and beyond. However, despite their proven impact, how CHWs navigate systemic challenges, engage communities, and integrate their roles within evolving health systems remain underexplored. Research that examines CHWs’ motivations, satisfaction, community acceptance and role perception when providing services in challenging environments is warranted. This qualitative descriptive study sought to generate an in-depth understanding of the experiences (i.e., roles, routines, successes/challenges, contributions, motivations etc.) of CHWs, providing care in rural and urban communities in Delhi, India during and after the COVID-19 pandemic, and the acceptance and perceptions of their roles by their beneficiaries and community leaders. This study aims to contribute to existing evidence that can help sustain CHW integration into existing healthcare systems, enhance healthcare equity, promote positive health outcomes, and reduce health disparities in India and beyond. METHODS Aim and Design of the study This study followed the Standards for Reporting Qualitative Research (SRQR), 10 to ensure study transparency and quality. Additionally, the study used a qualitative descriptive design to investigate the experiences of CHWs, in rural and urban communities in Delhi, India during and after the COVID-19 pandemic, and the acceptance and perceptions of their roles by their beneficiaries and community leaders. The Lévesque conceptual framework of access to healthcare 11 informed the development of this study, including data collection and analysis. Characteristics of Participants and Setting Community health workers: ASHA (n = 5), AWW (n = 4) and ANM (n = 3) who were active in their roles during and following the COVID-19 pandemic were recruited, along with beneficiaries (n = 5), who received care or services from CHWs during this time frame and community leaders (n = 4) who were familiar with CHWs’ roles, and in their leadership role during the pandemic. Participants were purposively sampled to capture demographic variations including: adult men and women, pregnant or postpartum women and Elders from the participating communities. Team members (i.e., SR, SS, FK) from Rufaida College of Nursing, Jamia Hamdard University (New Delhi, India) have strong connections with staff from various urban and rural health centers in catchment areas around Delhi, India. Their networks helped advertise the study and assist in recruiting the CHWs. For the beneficiaries and community leaders, team members from India also relied on their networks and sought assistance from local councilors to help advertise the study and recruit participants. A small honorarium was provided to all the participants. Individual, semi-structured interviews were conducted in quiet, private settings, such as clinic consultation rooms, participant’s homes, and community leader’s offices, to promote comfort, confidentiality and open dialogue. Data Collection The co-principal investigator (SR), a registered nurse and nursing Professor conducted the interviews (~ 60 minutes) in Hindi. Data was collected between March and May 2025 and consisted of field observations and semi-structured interviews. Field observations/notes were conducted concurrently with the interviews to provide context to the research setting and to complement participants’ narratives. Following Spradley’s nine dimensions guide, 12 observations focused on characteristics of the community (e.g., type of area, surrounding businesses), the clinic sites (e.g., size, hours of operation, staffing), and participants (e.g., verbal and non-verbal communication). Field observations provided contextual information that supported the team’s interpretation and analysis of the data, ensuring that the findings accurately reflected the local environment and participants’ lived realities. 13 Informed consent was obtained from all participants prior to participation. Three semi-structured interview guides were developed with the Lévesque conceptual framework¹¹ and guided by the five phases of interview guide development to ensure validity and trustworthiness.¹⁴ These included: (1) identifying the prerequisites for using semi-structured interviews, (2) drawing on existing knowledge, (3) formulating the preliminary interview guide, (4) pilot testing, and (5) finalizing the complete guide. 14 The interview guide was piloted with two CHWs in India to ensure that the questions were open-ended, clear, and aligned with the study’s objectives. Participants were encouraged to speak freely and share their experiences in a narrative manner, with follow-up questions posed to promote clarity and deeper understanding. All interviews were audio-recorded by the interviewer (SR) and transcribed verbatim. The transcripts were then translated from Hindi to English by a research assistant in India. To ensure accuracy and clarity, the interviewer (SR) reviewed the translations for both correctness and comprehensibility. Sampling continued until data saturation was reached; given the deductive nature of the analysis, saturation occurred when predetermined categories were adequately represented in the data. As noted by Francis et al., ¹⁵ saturation in this context is closely associated with content validity. 15 , 16 Data Analysis Translated transcripts and field notes were imported into NVivo version 14¹⁷ for data management and to support analysis. The first author, in close collaboration with the research team, conducted the analysis following the principles and guidelines of qualitative content analysis (QCA). ¹⁸ Content analysis is a systematic method used to generate valid and replicable inferences from textual data, to provide knowledge and representation of the phenomenon under study. The goal is to achieve a concise yet comprehensive description of the phenomenon through identification of meaningful categories and codes.¹⁸ Using a deductive QCA approach, the analytical structure was informed by the Lévesque conceptual framework 11 and proceeded through three phases: preparation, organization, and reporting.¹⁸ The preparation phase began with the selection of the unit of analysis, which is determined by the study’s research question(s) and objectives. According to Graneheim and Lundman,¹⁹ the most appropriate unit of analysis in QCA is typically, the entire interview transcript, as it is large enough to be viewed as a whole, yet sufficiently contained to provide contextual meaning during analysis. Following this recommendation, each transcript in their entirety was used for analysis. During this phase, the primary author (AS) also became deeply familiar with the data, reading and rereading the material to achieve immersion and develop an overall understanding of the content. ¹⁸ The organization phase involved developing a categorization matrix and coding the data according to predefined categories. For this study, a structured matrix was used, and only data that aligned with the predefined categories were included in the analysis. ²⁰ To guide this exploration, the Lévesque conceptual framework¹¹ was applied, as it has been effectively used to examine various healthcare models in previous research.²¹ , ²² This framework provides a multidimensional understanding of access and integration by conceptualizing them as interactions between an individual’s ability to access care and the characteristics of health systems or their providers that facilitate or hinder access. Its five dimensions on the supply end (i.e., approachability, acceptability, availability and accommodation, affordability, and appropriateness) and five corresponding abilities on the demand side (ability to perceive, seek, reach, pay and engage) offered a robust lens for analysis and interpretation. 11 During the reporting phase, results are presented as categories and codes, with clear descriptions of their content and meaning. To enhance the credibility and dependability of the findings, explicit links between the data and the resulting categories are demonstrated. ²³ To support transferability, a detailed description of the participant characteristics will be provided. For content validation, the research team collaboratively reviewed and reached consensus on the application of the Lévesque conceptual framework¹¹ and the categorization of data. RESULTS Participant Demographics: Community Health Workers Twelve CHWs (6 rural & 6 urban) were interviewed, including five ASHAs, three ANMs and four AWWs. All participants were female and married, except for one widowed participant. Ages ranged from 32–57 with a mean age of 46 years. Participants had substantial experience in their roles, ranging from ten to over 30 years, with a mean of 18.91 years. The population size each participant served varied widely, from approximately 1000 to over 15,000 individuals, with the highest coverage observed among ANMs. Main Findings (CHWs) Key findings from each category, organized using Lévesque conceptual framework, 11 are presented in Table 1 [insert Table 1 ]. Table 1 Categorization Matrix with Categories, Codes and # References for CHWs (n = 12) Category Code (# references) Code (# references) Code (# references) Approachability – How CHWs help community members identify and utilize health services and impact well-being Transparency (22) – CHW’s ability to disclose information accurately – both positive and negative Information sharing (22) – CHW’s ability to provide timely access to information- community health literacy Trust/respect (67)– CHW’s ability to obtain trust and respect from community members Acceptability- Cultural and societal factors- if aspects of services are acceptable & appropriate Professional Values (96) – How CHWs view roles, positive & negative aspects of role, salary & benefits Norms, Culture & Family (64) How culture, society and family create barriers or facilitators for role acceptance Motivations for becoming a CHW (31) Reasons or what prompted them to become a CHW Availability & Accommodation – Physical space and if CHWs can be reached in a timely manner, Community Needs (41) Services/health needs needed for their community that are and/or not available COVID-19 Impacts (125) – Impacts of the pandemic- both positive & negative Logistical (3) – Travel time to clinic, opening hours, flexibility Affordability Cost of services and related expenses, loss of income, travel time Financial Constraints (12) Unable to access private hospital or care and must rely on community/gov’t services No Financial Constraints Able to afford private care if warranted X Appropriateness – Fit between services provided and patient needs, time spent assessing health problems Quality of Care provided (182)- Training received, struggles with day-to-day operations Empowerment & Advocacy (22) Advocating for the community X Approachability Approachability was closely tied to the level of trust and respect that CHWs established within their communities. Participants consistently described how familiarity, accessibility, and mutual respect shaped their ability to reach community members and influence health-seeking behaviours. Community members often felt comfortable approaching CHWs directly, even visiting their homes when other means of contact were unavailable. As ASHA1 explained, “ If they don’t have a phone or if they can’t find me on the way, they come to my house.” Respect emerged as both a motivator and reward for their work. Several participants noted that their work was not driven by financial incentives but by community recognition: “ We work for respect only ” (ASHA1). Over time, sustained interactions fostered deep familiarity and trust, with one participant (AWW3) reflecting that, “ People have become more confident about us. In the initial years of my work as AWW, people did not trust us… but now people trust us and they send their kids.” This evolution of trust illustrates how repeated contact and demonstrated reliability transformed relationships from tentative to familial, as one participant described, “If you come to the same place, it becomes like a family. The people living in the area feel that they belong to the same family ” (AWW2). Participant’s ethical conduct further reinforced trust and credibility. Several participants emphasized that they refused gifts or money from community members, perceiving such gestures as threats to their professional integrity. “We don’t accept anything from people,” ANM2 explained, “ If they want to give us sweets, we take half a piece or one piece, not more than that.” This moral restraint strengthened the perception of CHWs as honest and dependable, which also, enhanced their approachability. For many community members, CHWs were seen as trusted intermediaries between the community and formal healthcare providers. As ASHA5 noted, “ If you go there, no matter how big a doctor you are, they won’t let you in their house, but if you go there with us, people will let you in… they trust us a lot.” However, some participants also acknowledged that approachability was not universal; some individuals preferred to seek care elsewhere or were less open to engagement. As ASHA4 noted: “… some people don’t want to talk to us because they go to the private clinic/hospitals”. Nonetheless, the overall pattern underscored that trust and respect were central to making services visible, approachable, and acceptable within the community. Acceptability Acceptability reflected how CHWs negotiated the alignment between their professional identity, community expectations, and cultural norms. Two interrelated codes, professional values and norms, culture, and family shaped how CHWs’ roles were perceived and accepted within their communities. Several participants expressed a deep sense of purpose and pride in their work, viewing it as meaningful and socially valuable despite limited financial recognition and heavy workloads. Some emphasized intrinsic motivation and moral commitment to serving others, as ASHA1 explained, “I like my work and I would go to any extent to do my work.” Others described the satisfaction of helping people across the lifespan, “ It feels good to save a child, it feels good to save a child after immunization, it feels very good” (ASHA5). While most participants acknowledged that their workload had increased since the COVID-19 pandemic, particularly from digital reporting, many continued to display perseverance and adaptability. “If there is a demand for some work and I don’t know how to do it, then I can learn it and do that work,” ASHA2 remarked, highlighting the commitment to ongoing learning despite limited resources. Participants also reflected on how social perceptions affected the acceptability of their role, noting that community members viewed their work as less important than that of doctors or facility-based staff. Nevertheless, many still asserted the dignity and value of their work: “ Many people think that our work is not good… but we don’t think that we do small or big work” (ASHA1). This professional pride and resilience reinforced their credibility and community trust, despite structural challenges such as low pay and poor technological infrastructure. Acceptability was also shaped by sociocultural and familial influences. Several participants faced opposition from family members, particularly mothers-in-law, who prioritized domestic responsibilities over paid work. As ASHA1 shared, “ My husband supports me a lot but my mother-in-law told me not to do it… when I go home, I feel like I am being insulted by them .” Another added, “ My mother-in-law doesn’t like it. She has conservative thinking” (ASHA2). These accounts highlight how traditional gender norms can limit women’s autonomy and the perceived legitimacy of their professional roles. However, others described supportive family environments that enabled them to thrive in their positions, as ANM1explained, “My brother-in-law supported me a lot… he agreed for my training as a CHW.” Cultural norms also influenced the scope of CHWs’ interactions within communities. Several noted that male community members were less likely to engage with them directly, as “mostly women talk to us; males usually don’t talk to us” (AWW4). These gendered communication patterns constrained the reach of health promotion activities, particularly those involving men’s health. Overall, the acceptability of CHWs’ work was strengthened by their ethical commitment, adaptability, and community-centred values, but was simultaneously challenged by gender and cultural norms. The intersection of professional pride and sociocultural expectations revealed that CHWs’ acceptability is not static but continuously negotiated within the social and cultural contexts in which they work. Availability & Accommodation This dimension reflects the accessibility of healthcare resources, and the extent to which CHWs could reach and serve communities in a timely and efficient manner. Participants described how the COVID-19 pandemic influenced the availability of essential supplies, service delivery, and their ability to safely interact with community members. During the initial phase of the pandemic, participants reported widespread shortages of masks, sanitizers, and gloves, often purchasing these items themselves. Despite inconsistent provision of protective equipment and delays in remuneration, they continued their duties, specifically when conducting household visits, distributing nutrient supplements and medicine, and assisting with COVID-19 surveillance. ASHA5 explained, “We were buying sanitizers with our own money in the initial days of COVID, but after two or four months, we started to get masks and gloves.” Another noted, “Sometimes we were getting masks and sanitizers and sometimes not, but the work didn’t stop” (ASHA2). The pandemic also catalyzed new modes of working and communication. Several described a shift toward digital reporting and mobile-based data sharing, which improved timeliness and oversight despite challenges. As ASHA1 reflected, “Earlier, I used to give oral contraceptives and condoms to houses, but now I go to their house and provide family planning information online immediately on our phone.” However, fears of contagion, transportation barriers, and increased workloads exacerbated stress and fatigue, highlighting the fragility of service delivery during crises. Beyond the pandemic, participants identified persistent infrastructure and resource constraints that limited their ability to meet community needs. Many described health centres as under-resourced and overcrowded, with insufficient equipment, space, and basic furnishings. One participant noted, “Right now, we are very worried about the chairs in the center. There are no chairs—we work standing up” (ASHA2). Another added, “This is a small dispensary… we can treat minor illnesses, not major ones. Our staff don’t have enough resources or training for that” (ANM1). Participants also emphasized the need for expanded services such as maternal care, diagnostic facilities, and health information for children. At the community level, mistrust of government facilities and low health literacy affected service utilization. As AWW3 observed, “People in this area are so illiterate. If anyone gives anything to them for free, they will come in bulk, but if anyone gives them health advice, they may not come at all.” Despite these barriers, participants continued to act as vital intermediaries, bridging service gaps, counselling families, and fostering trust between communities and the formal health system. Overall, findings highlight that while CHWs remained steadfast in their commitment to service, their effectiveness was often constrained by inadequate physical resources, insufficient institutional support, and uneven mechanisms during and after the COVID-19 pandemic. This underscores the need for sustained investments in basic infrastructure, digital tools, and responsive management systems to ensure that CHWs can accommodate and respond effectively to community health needs. Affordability Affordability, which relates to healthcare costs, lost income and time required for travel to access care, emerged as a key determinant of healthcare access, reflecting the interplay between economic vulnerability, indirect healthcare costs, and reliance on daily wages. Participants described their catchment populations as predominantly poor, with most households depending on unstable employment. Women were often unemployed or working as domestic helpers, while men engaged in low-income private jobs such as painting or construction, earning approximately Rupees 15,000–20,000 per month. As AWW1 noted, “Most of them are poor—most rely on daily wages. In my area, there are hardly two to four working women, and those who work are maids doing cleaning and cooking in people’s houses.” Limited and inconsistent income left families with little capacity to absorb healthcare-related expenses, including transportation, loss of wages, and purchasing medication. Although government health facilities provided free or low-cost services, indirect costs continued to impede access. One ASHA4 explained, “Some people are poor and they cannot afford these facilities from outside easily due to their financial conditions”. Participants emphasized that poverty also influenced healthcare-seeking behaviour, with many preferring local centres over private clinics due to affordability. They frequently identified and assisted vulnerable households, such as widows, the unemployed, and people with disabilities, in accessing government welfare schemes, yet noted that social assistance was often insufficient. The financial strain of the COVID-19 pandemic further compounded these challenges, as reflected by ASHA3, “Financially, everyone had a problem at that time, no matter how much one earned”. Overall, participants’ accounts highlight how economic hardship and indirect healthcare costs continue to shape health-seeking behaviours and limit service utilization. Their experiences support the need for sustained financial protection measures, strengthened welfare linkages, and flexible service delivery models that minimize costs for marginalized families. Appropriateness & Advocacy Appropriateness refers to the degree of fit between the services provided and the needs of the population, including timeliness and quality of care, and the ability of CHWs to spend sufficient time assessing and addressing health concerns. Participants provided a broad range of health services aligned with the needs of their communities, including vaccination, early childhood education, antenatal and postnatal care, assistance with family planning and distribution of nutrient supplements. Participants routinely adapted their work to meet community expectations, often working beyond regular hours to ensure continuity of care. One participant shared, “We don’t have any fixed holiday… if there’s a woman’s delivery case, we have to go on Sundays too with that lady to the hospital. We have to wait for the entire day in the hospital” (ASHA1). The increasing workload and expectations from supervisors also contributed to work intensification, yet CHWs continued to demonstrate commitment to timely and responsive service delivery. As one noted, “The number of patients are increasing… they ask that please give us a report on Sunday as well. You have to do a survey, you have to do it right now” (ASHA1). Participants highlighted that while basic services and medicines were generally available, some diagnostic and maternal services remained limited, requiring referrals to external facilities: “People can get free blood and urine tests here, everything is available here but ultrasound, X-rays and delivery for pregnant ladies have to be done from outside” (ASHA5). Despite these challenges, participants emphasized the value of ongoing training to improve their competencies and service quality. As expressed by ANM3, “We get training for everything—family planning, NCDs, and safe immunization. We get training once or twice a month” . Participants also positioned themselves as advocates, particularly for the elderly, women, and low-income families. Their advocacy often extends beyond health to include social entitlements and community well-being. One participant noted, “A lot of women tell me that they haven’t received their old age pension, so I tell them to go to the MLA office… we motivate them to apply for old age pension” (AWW2). Participants expressed personal satisfaction in empowering beneficiaries with knowledge and access to care. As ANM2 described, “The poor population in this area doesn’t know what diet to take… so sometimes women get miscarriages or don’t know how to give birth properly. We guide them at that time and ensure that they don’t have any problem” . Similarly, ASHA4 emphasized engaging men in family planning to alleviate the reproductive burden on women: “We give more knowledge to the male members of the family to motivate them to go for male family planning operations so that the ladies don’t have to face so many problems.” These findings underscore the CHWs’ dual role as both healthcare providers and social advocates. Their work reflects a commitment to equity and empowerment of their communities, highlighting their integral role in bridging the gap between the health system and vulnerable populations. Participant Demographics: Beneficiaries & Community Leaders A total of five beneficiaries and four community leaders participated in the interviews. All community leaders were male, while only one beneficiary identified as male. Beneficiaries ranged in age from 31–45 years and community leaders from 40–65 years, with a combined mean age of 42.66 years. All participants were married, and one beneficiary was pregnant at the time of the interview. Most beneficiaries had no formal education and, aside from one individual, were homemakers; only two out of five beneficiaries lived in rural areas. In contrast, most community leaders had completed university education and resided in urban communities. Main Findings: Beneficiaries and Community Leaders For the beneficiaries and community leaders, we applied the complementary user-side dimensions of the Lévesque framework, 11 which describe the abilities required to access care: (1) ability to perceive, (2) ability to seek, (3) ability to reach, (4) ability to pay, and (5) ability to engage. A categorization matrix was similarly developed to align these abilities with relevant codes and reference frequencies (Table 2 )[insert Table 2 here]. The three most prominent categories: ability to perceive, ability to reach, and ability to engage, accounted for most coded references. Therefore, our description highlights these key abilities, as they most clearly illustrate how participants experienced and navigated access to healthcare in relation to CHW roles. Table 2 Categorization Matrix with Categories, Codes and # References for Beneficiaries (n = 5) & Community Leaders (n = 4) Category Code (#references) Code (#references) Code (#references) Ability to perceive- an individual’s health literacy, health beliefs, trust and expectation Transparency (2)- CHW’s ability to disclose information accurately- both positive and negative Information Sharing (6) CHW’s ability to provide timely access to information, ensures health literacy Trust/respect (13) CHW’s ability to obtain trust and respect from community members Ability to seek- personal and social values, culture, gender & autonomy Professional Values (6)- how CHW’s roles are perceived Norms Culture & Family (4), How culture, society and their family create barriers and facilitators for Motivations for becoming a CHW (0) what community perceive as the motivation for this role Ability to reach- living environments, mobility and social supports Community Needs (17) services and health needs of the community COVID-19 Impact (20) Impacts of the pandemic, both positive & negative Logistical (4) Travel time to clinic, flexibility in hours of operation Ability to pay- income, assets and health insurance Financial Constraints (3) unable to access private hospitals and must rely on community/gov’t services No financial Constraints (0)– Able to afford private care if warranted X Ability to engage- empowerment, information adherence and caregiver support Quality of Care Provided (23) CHW’s training, competency, Empowerment & Advocacy (1) – How CHWs empower and advocate for their community X Ability to Perceive: How beneficiaries and community leaders understand and interpret their need for care and the role of CHWs Participants’ ability to recognize their health needs and identify where to seek care was strongly shaped by their perceptions of CHWs as approachable, trustworthy, and deeply embedded within the community. Many beneficiaries described relying on CHWs for guidance, often consulting them alongside family members and doctors when health concerns arose. As one beneficiary explained, “We consult with the family members and the doctors and CHWs in this center who come our home and meet us” (B2). Another noted that the increased visibility of CHWs over time improved community awareness of available services: “Nobody [ASHA] came to my house to tell anything about delivery… but now the situation has changed. Now ASHA workers come and give advice to people, yes, they talk nicely” (B4). Trust in CHWs was a recurring theme that reinforced participants’ confidence in recognizing when care was needed. Beneficiaries repeatedly emphasized this trust, stating, “I have faith in them and their services” (B1), and “Yes, we do respect them” (B2). Community leaders echoed this sentiment, confirming that “people respect CHWs” and that individuals frequently relied on them for advice, noting that “people have ASHA worker’s phone numbers… [and] can call them anytime for any health-related problems” (B3; C1). Familiarity and shared community identity further strengthened participants’ perceptions of CHWs as credible and accessible sources of information. Community leaders highlighted that CHWs’ embeddedness within the community increased comfort and trust: “Mostly CHWs are local people of this area… they know each and every house of their population, so people feel comfortable with them” (C2). Another added, “People are very comfortable with CHWs… they are part of this community only” (C3). Their involvement in tasks beyond health, such as distributing election cards or updating voting lists, also reinforced their legitimacy and visibility within local structures. These perceptions were amplified during the COVID-19 pandemic, when CHWs took on heightened roles in helping, providing information, and support under difficult circumstances. One community leader described how their commitment reshaped public awareness of their value: “CHWs were valued so much in COVID time… they were valued more than doctors and people respected them as ‘God’ during COVID” (C4). Their advice was trusted and closely followed, as reflected in the observation that “If any CHW said… you have to stay quarantined for 14 days, community people were listening… and following carefully” (C4). Collectively, these narratives show that beneficiaries’ and community leaders’ ability to perceive health needs was facilitated by strong trust, familiarity, and comfort with CHWs, who served as credible and accessible sources of health information and awareness. Ability to Reach – How Beneficiaries lived, travelled to healthcare facilities and social supports Participants identified several factors that shaped their ability to physically access healthcare services, including infrastructure limitations, time and travel burdens and the extensive disruptions from the COVID-19 pandemic. Many beneficiaries highlighted the challenges posed by limited diagnostic and facility resources at the health centre. As B5 explained, although routine care was available, “these machines for ultrasounds and X-rays should be available… if they had these machines, we wouldn’t have had any problem” (B3). Pregnant women were particularly affected, with one beneficiary noting that “ultrasound and X-ray facilities are not available here… we have to get these services from outside, and that becomes very difficult” . Basic infrastructure deficiencies, such as the absence of drinking water and poor sanitation, also constrained accessibility, with participants describing the beneficiary toilets as “too dirty… there is no water” (B5). Travel and time burdens further limited individuals’ ability to reach care. Participants described the inconvenience and long travel times required for off-site diagnostics, stating, “we have to go to the hospital every month… it takes a lot of time” (B3). Health centre operating hours also did not align with the schedules of working adults and school-aged children. Several recommended extended hours to increase access, explaining that “all the men and women are doing work, no one can come here in the morning” and that children were also unable to attend during school hours (B1). Another participant emphasized that evening availability “would benefit people who have to go to work in the morning” (B2). Participants also described environmental and occupational factors that shaped access needs. Community leaders reported a history of respiratory and occupational health problems in areas with high exposure to dust and pollution, noting that “there were a lot of health problems… because the population was involved in labour work” (CL1). Others highlighted the burden of chronic conditions, explaining that “most people have diabetes and blood pressure… people are alcohol addicted” (CL4), further increasing the community’s need to reach regular care. The COVID-19 pandemic significantly disrupted physical access to services. Many experienced severe financial strains from job loss, with B1 explaining that it became “very difficult to eat and drink at home due to poor financial conditions… my husband’s work was closed” . Lockdowns restricted movement, and some described not leaving their homes at all: “I never used to go out of the house… everything was closed” (B3). Community leaders also described resource shortages and widespread hardship, including “shortage of oxygen cylinders” and difficulties accessing hospital care (CL2). Yet, community support networks partly mitigated these barriers, as leaders explained that “if someone needed food or medicines, we provided help” (CL1). Overall, participants’ ability to reach healthcare was shaped by a combination of structural, environmental, and pandemic-related constraints, compounded by inconsistent facility resources and challenging socio-economic conditions. Ability to Engage- How Well Beneficiaries Feel Informed, Empowered and Supported by Caregivers and Able to Follow Recommended Care Participants described high levels of engagement with CHWs, facilitated by outreach, positive interpersonal interactions, and a strong sense of trust and familiarity within the community. Many beneficiaries explained that their initial connection to the health centre was established through CHW home visits. One beneficiary described how engagement began when “ASHA sister came to our house… she used to tell me about the treatment and medicines” (B2). Such outreach was also emphasized by community leaders, who noted that CHWs “visit each and every home… give medicines and vaccinations to the children and pregnant ladies” (CL2). Interpersonal relationships and respectful communication played an important role in supporting engagement with services. Beneficiaries frequently described positive experiences, stating, for example, “everyone is good here, they behave very well with their patients. I feel good about it” (B3). Similarly, community leaders highlighted widespread satisfaction, explaining that “people are happy with their work… CHWs are working really hard for improving people’s health” (CL2). Participants also described how engagement varied depending on the perceived severity of illness. One beneficiary explained that she typically used the centre for minor issues, stating, “If there is big illness I go to private clinic or hospital, but if there is small problem like cold and cough I prefer to come to this center” (B4). This pattern reflected CHWs’ roles in facilitating ongoing, low-acuity care while more severe conditions were seen as requiring external services. Despite strong engagement, participants identified several structural barriers that limited CHWs’ ability to support sustained care. Some beneficiaries emphasized the need for improved training and resources, suggesting that CHWs should “tell people to come after a week when resources would be available” if supplies were lacking (B2). Community leaders similarly noted gaps in training and system capacity, stating that “If they get more training, it would be better… more than training, emergency health care services in health centres are important” (CL3). Low salaries and high workloads especially for ASHAs were also cited as major constraints, with leaders observing that CHWs “have been given a lot of workload” and that their “salary should be increased” (CL4). Engagement was also shaped by ongoing collaboration between CHWs and community leaders. Leaders routinely interacted with CHWs for tasks such as document verification, describing CHWs as “active” and “working very well” (CL1). These interactions strengthened relationships and reinforced community confidence in CHWs. Overall, participants described a supportive and trusting environment where CHWs played a central role in facilitating engagement with the health system. However, sustained engagement was challenged by systemic issues including inadequate resources, limited training and heavy workloads. DISCUSSION This qualitative descriptive study aimed at developing an in-depth understanding of CHW’s roles, routines, successes and challenges, contributions, and motivations as they delivered care in rural and urban communities in Delhi, India during and after the COVID-19 pandemic. We also explored how their roles were perceived and accepted by beneficiaries and community leaders. To guide this work, we applied the Lévesque conceptual framework. 11 Our findings highlight the central role of approachability, trust and respect in the effectiveness of CHWs in both rural and urban settings. Consistent with prior research, 24,25 CHWs’ familiarity, accessibility, and ethical conduct were critical in fostering trust and credibility within their communities, enabling them to influence health-seeking behaviours effectively. Our findings also suggest that recognition and respect, rather than financial renumeration alone, serve as powerful motivators for CHWs, particularly for ASHAs, who consistently emphasized the value of social appreciation in sustaining their commitment to their roles and increasing workloads. This aligns with other research demonstrating that CHWs often derive a strong sense of role identity, duty and purpose from community validation, especially when remuneration is limited or inconsistent. Studies in Nepal, 26 Ethiopia, 27 and Kenya, 28 where volunteer or minimally compensated CHWs form the backbone of primary care delivery, showed similar results. In these studies, non-financial motivators such as social status, trust, and community gratitude partially compensated for lack of pay; however, such recognition does not replace the need for fair and reliable compensation. This complexity was especially apparent among the ASHA participants, who receive the lowest fixed income among the three CHW cadres (i.e., 3000 INR (~ $ 33 USD) per month) and therefore relied heavily on task-based incentives to supplement their earnings. For instance, ASHAs receive additional compensation when a child is vaccinated or when a woman delivers in a healthcare facility. This structure places them in a position where the distinction between “working harder” out of financial necessity versus intrinsic motivation becomes difficult to disentangle. While many expressed a genuine desire to help their community, the incentive-based structure raises questions about whether increased effort is driven by commitment to community health, financial pressure, or both. Community leaders also highlighted the disparity between CHWs’ heavy workloads and their limited pay, reinforcing concerns that inadequate remuneration contributes to stress, role strain, and long-term sustainability. Whether CHWs should work as volunteers or be compensated remains a point of debate; however evidence suggests that volunteerism is difficult to sustain over long periods, particularly in low to middle income countries like India where many CHWs experience financial insecurity and rely on this work for income. 24 Although many CHW programs are designed with the expectation that workers spend only a small portion of their time on health-related duties, community needs often demand full-time engagement. 24 In our study, ASHA workers receive higher pay for task-based activities, creating tension between the expectation of part-time work and the pressures to take on additional tasks to increase earnings. This mismatch between workload, compensation, and community expectations underscores the need to reconsider remuneration models to support both CHW well-being and program sustainability. In our study, several CHWs also described experiencing tension with family members, especially mothers-in-law who discouraged their role. This conflict highlights a deeper struggle between role identify and prevailing sociocultural expectations especially with respect to gender-based norms and roles. Such dynamics however are not unique to our study. Research from other low to middle income countries has also documented similar challenges. In a systematic review and qualitative meta-analysis of 38 studies on the sociocultural factors impacting CHWs in South Asia, the authors found that CHWs regularly faced challenges due to religious and cultural norms, gender and generational issues. 29 Our findings suggest that programmatic efforts to support CHWs must go beyond training and remuneration, but engaging family systems and fostering sociocultural legitimacy for the CHW role may be just as important for sustainability. While in high-income settings the precise nature of these conflicts may differ, similar tensions around professional commitment versus family and community expectations can still arise, particularly in settings where CHWs come from marginalized or close-knit communities. For example, a Canadian study examining Indigenous CHWs in remote northern communities found that workers often experienced intense pressure and expectations from community members, many of whom were relatives. 30 These communities, often characterized by small populations where “everyone knows everyone”, created additional challenges. One major concern centred around confidentiality: some community members felt uncomfortable sharing personal health information with CHWs for fear that it might not remain private. 30 Unlike the more populous and diverse settings in India, these small northern communities amplify the social and cultural proximity between CHWs and residents, shaping both the expectations placed on CHWs and the relational complexities of their work. Finally, the COVID-19 pandemic introduced profound complexities for CHWs and their communities. Participants described a dramatic increase in workload alongside a rapid shift toward digital technologies for surveillance, reporting and communication. Many struggled with basic tools like phones that malfunctioned, unreliable network connectivity, and unfamiliar apps, highlighting the digital divide that remains prevalent today. These challenges were further compounded by longstanding resource shortages, including limited access to clean water, sanitation, and essential supplies all of which were magnified during the pandemic. Importantly, because CHWs are positioned at the frontline, community frustrations with systemic inadequacies were often directed toward them despite these issues being beyond their control. Similar patterns were documented globally, even in high income countries, nurses and other frontline providers faced parallel struggles with rapidly evolving technology demands, insufficient equipment, and overwhelming workloads. 31 Taken together, these findings reinforce that pandemic related strains were not unique to CHWs in India but part of a broader, international pattern of health system vulnerability. CONCLUSIONS This study provides an in-depth understanding of how CHWs navigate complex community needs and integrate healthcare within constrained environments. A particular strength is the rich contextual insights from close collaboration with the local interviewer and observational field notes, which helped anchor the findings despite that some of the research team was not present in India during data collection. However, this absence is also a limitation, as is the study’s focus on one geographic region and specific mix of participants, which may limit transferability to other contexts. Additionally, as with all qualitative studies, the findings reflect interpretation within a defined methodology and may not capture the full breadth of CHW experiences across India’s diverse sociocultural landscape. Nevertheless, the study highlights areas for future research, including the need to better understand sociocultural influences on CHWs’ professional identities, sustainability of incentive-based remuneration models, and the long-term impacts of digital technologies. Strengthening CHW programs will require sustained attention to fair compensation, ongoing training (including digital literacy), supportive supervision, and engagement with families and communities to reduce sociocultural tensions. Investing in these supports will not only enhance CHW well-being and performance but also bolster the critical role they play in advancing equitable, community-centred healthcare globally. Abbreviations ANMS Auxiliary Nurse Midwives ASHAs Accredited Social Health Activists AWWs Anganwadi Worker CHW Community Health Worker SRQR Standards for Reporting Qualitative Research QCA qualitative content analysis Declarations Ethics Approval and Consent to Participate This study received ethical approval from Dalhousie University, Nova Scotia, Canada (REB # 2024 − 744) and from Jamia Hamdard University, New Delhi, India (Ref. No. 12/24 (12/11/2024). All participants provided written, informed consent. The study was conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2) and the principles of the Declaration of Helsinki. Consent for Publication Not applicable Competing Interests The authors declare that they have no competing interests Funding Funding for this study has been made possible by a peer reviewed, Research Nova Scotia, 2024-25 International Nursing Research Program Award. Author Contribution All authors read and approved the final manuscript. SR, SS and FK were primarily responsible for recruitment and consenting of participants, data collection, reviewing transcribed/translated transcripts, obtaining field notes and reviewing the data analysis. AI provided insights into the data analysis, presentation of the results and discussion. ND was responsible for final editing of the manuscript, references and supplementary material. AS was the primary investigator of the study, analyzed the data, wrote the manuscript and collaborated with the research team for feedback, edits and final submission. Acknowledgments Not applicable Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Peretz PJ, Islam N, Matiz LA. Community Health Workers and COVID-19- Addressing Social Determinants of Health in Times of Crisis and Beyond. N Engl J Med. 2020. 10.1056/NEJMp2022641 . Phelan H, Yates V, Lillie E. Challenges in healthcare delivery in low-and-middle- income countries. Anaesth Intensive Care Med. 2022;23(8):501–4. Balcazar H, Rosenthal L, Brownstein JN, Rush CH, Matos S, Hernandez L. Community health workers can be a public health force for change in the United States: three actions for a new paradigm. Am J Public Health. 2011;101(12):2199–201. Perry HB, Zulliger R, Rogers MM. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness. Annu Rev Public Health. 2014;35:399–421. CHW training. 15 Community Health Worker Job Titles and Different Roles [Internet]. [cited 2025 Nov9]. Available from https://chwtraining.org/15-community-health-worker-job-titles-and-different-roles/ Saprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health. 2015;13:95. Patel AR, Nowalk MP. Expanding immunization coverage in rural India: A review of evidence for the role of community health workers. Vaccine. 2010;28(3):604–13. Boyce MR, Katz R. Community Health Workers and Pandemic Preparedness: Current and Prospective Roles. Front Public Health. 2019;7:62. 10.3389/fpubh.2019.00062 . Steenbeek A, Gallant A, MacDonald NE, Curran J, Graham JE. Nova Scotia Strong: why communities joined to embrace COVID-19 public health measures. Can J Public Health. 2022;113(Suppl 1):4–13. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. 10.1097/ACM.00000000000000388 . Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualizing access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. 10.1186/14759276-12-18 . Spradley J. Participant observation. Reissued ed. Long Grove, IL: Waveland Press; 2016. xi, 195 p. Chabot C, Shoveller J. Observations and Interviews. In: Shoveller J, Chabot C, Oliffe J, Gilbert M, editors. Designing and conducting gender, sex, and health research. Thousand Oaks, CA: SAGE Publications; 2011. p.105. Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954–65. 10.111/jan.13031. Francis JJ, Johnston M, Robertson C, Glidewell L, Entwhistle V, Eccles MP, Grimshaw JM. What is an adequate sample size? Operationalising data saturation for theory-driven interview studies. Psychol Health. 2010;25(10):1229–45. 10.1080/08870440903194015 . Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907. 10.1007/s11135-017-0574-8 . Lumivero. NVivo [computer software]. Version 14.2023. Available from: https://www.lumivero.com Elo S, Kyngas H. The qualitative content analysis process. J Clin Nurs. 2008;62(1):107–15. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–12. Sandelowski M. Qualitative analysis: what it is and how to begin? Res Nurs Health. 2005;18:371–5. Cu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque’s conceptual framework: a scoping review. Int J Equity Health. 2021;20:116. 10.1186/s12939-021-01416-3 . Levesque JF, Sutherland K. Combining patient, clinical and system perspectives in assessing performance in healthcare: an integrated measurement framework. BMC Health Serv Res. 2020;20:23. 10.1186/s12913-019-4807-5 . Flanagan J, Beck CT. Polit and Beck’s Nursing Research: Generating and Assessing Evidence for Nursing Practice. 12th ed. New York: Wolters Kluwer Health, Lippincott, Williams & Wilkins; 2025. [e-book]. Lehmann U, Sanders D, Impact on Health Outcomes of Using Community Health Workers. Community Health Workers: What Do We Know about Them. The State of the Evidence on Programmes, Activities, Costs and. Geneva: World Health Organization; 2007. [Internet]. [cited 2025 Nov 21]. Available from https://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf Grant M, Wilford A, Haskins L, Phakathi S, Mntambo N, Horwood CM. Trust of community health workers influences the acceptance of community- based maternal and child health services. Afr J Prim Health Care Fam Med. 2017;9(1):e1-e7. Available from: https://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf Bashyal LK. Payment and Motivation: Female Community Health Volunteers in Nepal. Dhaulagiri J Sociol Anthropol. 2023;17(1):39–44. 10.3126/dsaj.v17i01.61143 . Jigssa HA, Desta BF, Tilahun HA, McCutcheon J, Berman P. Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions. Hum Resour Health. 2018;16:57. 10.1186/s12960-018-0319-3 . Takasugi T, Lee ACK. Why do community health workers volunteer? A qualitative study in Kenya. Public Health. 2012;126(10):839–45. 10.1016/j.puhe.2012.06.005 . Majid U, Zahid M, Harold K, Zain S, Sood T. Challenges in the sociocultural milieu of South Asia: A systematic review of community health workers. Rural Remote Health. 2021;21(4): 1–13. Available from: https://search.informit.org /doi/10.3316/informit.299463446498108 Oosterveer MT, Young KT. Primary health care accessibility challenges in remote Indigenous communities in Canada’s North. Int J Circumpolar Health. 2015;74(1):29576. 10.3402/ijch.v74.29576 . Billings J, Ching BCF, Gkofa V, Greene T, Bloomfield J. Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: a systematic review and qualitative meta-synthesis. BMC Health Serv Res. 2021;21:923. 10.1186/s12913-021-06917-z . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9141682","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626057452,"identity":"79be2f3e-1644-4029-ac6c-c6e8cb94ae5a","order_by":0,"name":"Audrey Steenbeek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIie3NoQrCUBTG8TMGWzly67HoK+w2gw+jCNosKwbDZHBXRKuCvoNv4IUL17IHUBScRYthSSyKCyaDdzbD/bUD588HYFl/rAXgORlCo9S3E70TN0Cg3xKPSiUs8i9ZPjj0mS+6g+uQgCXye0IS+WiWnsPqWOvdQhNQ2jLMSHTiilDt1bYn9ugRBGBI6tI/xY+naq+PFxHis0hY9j0JJPDYiYoV8rRbEUVChhWukM/HWoWUdjvV5YSQtoaV2ibJ8vtQ9VmieX69NWtsalgB9+NGw79lWZZVxguQ7ES37XxikAAAAABJRU5ErkJggg==","orcid":"","institution":"Dalhousie University","correspondingAuthor":true,"prefix":"","firstName":"Audrey","middleName":"","lastName":"Steenbeek","suffix":""},{"id":626057453,"identity":"a0882aff-5f2c-4d5d-a45e-0b48b6b54092","order_by":1,"name":"Seema Rani","email":"","orcid":"","institution":"Jamia Hamdard University, Rufaida College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Seema","middleName":"","lastName":"Rani","suffix":""},{"id":626057454,"identity":"0b616c99-a86b-4ee8-b0fb-65d270e0681e","order_by":2,"name":"Noah Doucette","email":"","orcid":"","institution":"Dalhousie University","correspondingAuthor":false,"prefix":"","firstName":"Noah","middleName":"","lastName":"Doucette","suffix":""},{"id":626057455,"identity":"7daa09cd-4729-42e9-8f4b-41b5a1198428","order_by":3,"name":"Fareha Khan","email":"","orcid":"","institution":"Jamia Hamdard University, Rufaida College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Fareha","middleName":"","lastName":"Khan","suffix":""},{"id":626057456,"identity":"5648a5c7-0800-4313-9b15-7832253b4c83","order_by":4,"name":"Shilpi Sarkar","email":"","orcid":"","institution":"Jamia Hamdard University, Rufaida College of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Shilpi","middleName":"","lastName":"Sarkar","suffix":""},{"id":626057458,"identity":"bf75004a-c40f-482b-bab8-c088ffea8cf7","order_by":5,"name":"Alyssa Indar","email":"","orcid":"","institution":"University Health Network","correspondingAuthor":false,"prefix":"","firstName":"Alyssa","middleName":"","lastName":"Indar","suffix":""}],"badges":[],"createdAt":"2026-03-16 20:38:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9141682/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9141682/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107706568,"identity":"174b21ce-a64a-4c61-9833-a3de25984fac","added_by":"auto","created_at":"2026-04-24 09:18:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":349037,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9141682/v1/cdb2510d-bdb1-49b8-a4cc-1aa4383f1219.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Exploration of Community Health Workers’ Roles and Motivations in Delivering Care During and After the COVID-19 Pandemic: Experiences and Community Perceptions in Rural and Urban Delhi, India","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eHealthcare systems are often strained by workforce and resource shortages, and although these challenges are not new, the COVID-19 pandemic exacerbated the strain on healthcare worldwide, prompting innovative approaches to healthcare delivery.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In many low to middle income countries like India, these shortages predated the pandemic and historically, hindered equitable access to healthcare.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe integration of community health workers (CHWs) into healthcare systems has evolved as a strategy to enhance equitable access and quality of care.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e CHWs, also known as health navigators or health promoters among others,\u003csup\u003e5\u003c/sup\u003e are trusted community members with targeted training to deliver a range of services. Their position within their communities enables them to bridge formal healthcare systems with the populations they serve, mitigating persistent health inequities.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEvidence demonstrates, that when CHWs are integrated into existing healthcare systems they improve health outcomes, including disease prevention (e.g., vaccination),\u003csup\u003e1,3\u003c/sup\u003e enhanced patient-provider communication and trust,\u003csup\u003e1,3,7\u003c/sup\u003e treatment adherence,\u003csup\u003e1,4,7\u003c/sup\u003e and linkage to health and social services.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e They also support the management of chronic diseases like diabetes and hypertension,\u003csup\u003e4\u003c/sup\u003e facilitate cancer screening,\u003csup\u003e4\u003c/sup\u003e and improve maternal and child outcomes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn India, CHWs or Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and Auxiliary Nurse Midwives (ANMs), are central to the success of community-based health initiatives.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e They help provide family planning/contraception, conduct home visits, promote maternal and child health, and collect census data, while promoting public health awareness.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Their strengths lies in their ability to establish interpersonal relationships grounded in their community\u0026rsquo;s cultural understanding, trust, and shared experience. By prioritizing these social bonds, CHWs in India, have effectively tailored healthcare to local contexts, accounting for language, norms, and community values.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e During the COVID-19 pandemic, many CHWs also helped address misinformation and fear surrounding the virus by providing timely and accurate information to their communities about transmission and precautions including vaccination, quarantine, testing and masks.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThrough these efforts, CHWs have become indispensable to the delivery of equitable and culturally responsive care in India and beyond. However, despite their proven impact, how CHWs navigate systemic challenges, engage communities, and integrate their roles within evolving health systems remain underexplored. Research that examines CHWs\u0026rsquo; motivations, satisfaction, community acceptance and role perception when providing services in challenging environments is warranted. This qualitative descriptive study sought to generate an in-depth understanding of the experiences (i.e., roles, routines, successes/challenges, contributions, motivations etc.) of CHWs, providing care in rural and urban communities in Delhi, India during and after the COVID-19 pandemic, and the acceptance and perceptions of their roles by their beneficiaries and community leaders. This study aims to contribute to existing evidence that can help sustain CHW integration into existing healthcare systems, enhance healthcare equity, promote positive health outcomes, and reduce health disparities in India and beyond.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim and Design of the study\u003c/h2\u003e \u003cp\u003eThis study followed the Standards for Reporting Qualitative Research (SRQR),\u003csup\u003e10\u003c/sup\u003e to ensure study transparency and quality. Additionally, the study used a qualitative descriptive design to investigate the experiences of CHWs, in rural and urban communities in Delhi, India during and after the COVID-19 pandemic, and the acceptance and perceptions of their roles by their beneficiaries and community leaders. The L\u0026eacute;vesque conceptual framework of access to healthcare\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e informed the development of this study, including data collection and analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCharacteristics of Participants and Setting\u003c/h3\u003e\n\u003cp\u003eCommunity health workers: ASHA (n\u0026thinsp;=\u0026thinsp;5), AWW (n\u0026thinsp;=\u0026thinsp;4) and ANM (n\u0026thinsp;=\u0026thinsp;3) who were active in their roles during and following the COVID-19 pandemic were recruited, along with beneficiaries (n\u0026thinsp;=\u0026thinsp;5), who received care or services from CHWs during this time frame and community leaders (n\u0026thinsp;=\u0026thinsp;4) who were familiar with CHWs\u0026rsquo; roles, and in their leadership role during the pandemic. Participants were purposively sampled to capture demographic variations including: adult men and women, pregnant or postpartum women and Elders from the participating communities. Team members (i.e., SR, SS, FK) from Rufaida College of Nursing, Jamia Hamdard University (New Delhi, India) have strong connections with staff from various urban and rural health centers in catchment areas around Delhi, India. Their networks helped advertise the study and assist in recruiting the CHWs. For the beneficiaries and community leaders, team members from India also relied on their networks and sought assistance from local councilors to help advertise the study and recruit participants. A small honorarium was provided to all the participants. Individual, semi-structured interviews were conducted in quiet, private settings, such as clinic consultation rooms, participant\u0026rsquo;s homes, and community leader\u0026rsquo;s offices, to promote comfort, confidentiality and open dialogue.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThe co-principal investigator (SR), a registered nurse and nursing Professor conducted the interviews (~\u0026thinsp;60 minutes) in Hindi. Data was collected between March and May 2025 and consisted of field observations and semi-structured interviews. Field observations/notes were conducted concurrently with the interviews to provide context to the research setting and to complement participants\u0026rsquo; narratives. Following Spradley\u0026rsquo;s nine dimensions guide,\u003csup\u003e12\u003c/sup\u003e observations focused on characteristics of the community (e.g., type of area, surrounding businesses), the clinic sites (e.g., size, hours of operation, staffing), and participants (e.g., verbal and non-verbal communication). Field observations provided contextual information that supported the team\u0026rsquo;s interpretation and analysis of the data, ensuring that the findings accurately reflected the local environment and participants\u0026rsquo; lived realities.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Informed consent was obtained from all participants prior to participation.\u003c/p\u003e \u003cp\u003eThree semi-structured interview guides were developed with the L\u0026eacute;vesque conceptual framework\u0026sup1;\u0026sup1; and guided by the five phases of interview guide development to ensure validity and trustworthiness.\u0026sup1;⁴ These included: (1) identifying the prerequisites for using semi-structured interviews, (2) drawing on existing knowledge, (3) formulating the preliminary interview guide, (4) pilot testing, and (5) finalizing the complete guide.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The interview guide was piloted with two CHWs in India to ensure that the questions were open-ended, clear, and aligned with the study\u0026rsquo;s objectives.\u003c/p\u003e \u003cp\u003e Participants were encouraged to speak freely and share their experiences in a narrative manner, with follow-up questions posed to promote clarity and deeper understanding. All interviews were audio-recorded by the interviewer (SR) and transcribed verbatim. The transcripts were then translated from Hindi to English by a research assistant in India. To ensure accuracy and clarity, the interviewer (SR) reviewed the translations for both correctness and comprehensibility. Sampling continued until data saturation was reached; given the deductive nature of the analysis, saturation occurred when predetermined categories were adequately represented in the data. As noted by Francis et al., \u0026sup1;⁵ saturation in this context is closely associated with content validity.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eTranslated transcripts and field notes were imported into NVivo version 14\u0026sup1;⁷ for data management and to support analysis. The first author, in close collaboration with the research team, conducted the analysis following the principles and guidelines of qualitative content analysis (QCA). \u0026sup1;⁸ Content analysis is a systematic method used to generate valid and replicable inferences from textual data, to provide knowledge and representation of the phenomenon under study. The goal is to achieve a concise yet comprehensive description of the phenomenon through identification of meaningful categories and codes.\u0026sup1;⁸ Using a deductive QCA approach, the analytical structure was informed by the L\u0026eacute;vesque conceptual framework\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e and proceeded through three phases: preparation, organization, and reporting.\u0026sup1;⁸ The preparation phase began with the selection of the unit of analysis, which is determined by the study\u0026rsquo;s research question(s) and objectives. According to Graneheim and Lundman,\u0026sup1;⁹ the most appropriate unit of analysis in QCA is typically, the entire interview transcript, as it is large enough to be viewed as a whole, yet sufficiently contained to provide contextual meaning during analysis. Following this recommendation, each transcript in their entirety was used for analysis. During this phase, the primary author (AS) also became deeply familiar with the data, reading and rereading the material to achieve immersion and develop an overall understanding of the content. \u0026sup1;⁸\u003c/p\u003e \u003cp\u003e The organization phase involved developing a categorization matrix and coding the data according to predefined categories. For this study, a structured matrix was used, and only data that aligned with the predefined categories were included in the analysis. \u0026sup2;⁰ To guide this exploration, the L\u0026eacute;vesque conceptual framework\u0026sup1;\u0026sup1; was applied, as it has been effectively used to examine various healthcare models in previous research.\u0026sup2;\u0026sup1;\u003csup\u003e,\u003c/sup\u003e \u0026sup2;\u0026sup2; This framework provides a multidimensional understanding of access and integration by conceptualizing them as interactions between an individual\u0026rsquo;s ability to access care and the characteristics of health systems or their providers that facilitate or hinder access. Its five dimensions on the supply end (i.e., approachability, acceptability, availability and accommodation, affordability, and appropriateness) and five corresponding abilities on the demand side (ability to perceive, seek, reach, pay and engage) offered a robust lens for analysis and interpretation.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDuring the reporting phase, results are presented as categories and codes, with clear descriptions of their content and meaning. To enhance the credibility and dependability of the findings, explicit links between the data and the resulting categories are demonstrated. \u0026sup2;\u0026sup3; To support transferability, a detailed description of the participant characteristics will be provided. For content validation, the research team collaboratively reviewed and reached consensus on the application of the L\u0026eacute;vesque conceptual framework\u0026sup1;\u0026sup1; and the categorization of data.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Demographics: Community Health Workers\u003c/h2\u003e \u003cp\u003eTwelve CHWs (6 rural \u0026amp; 6 urban) were interviewed, including five ASHAs, three ANMs and four AWWs. All participants were female and married, except for one widowed participant. Ages ranged from 32\u0026ndash;57 with a mean age of 46 years. Participants had substantial experience in their roles, ranging from ten to over 30 years, with a mean of 18.91 years. The population size each participant served varied widely, from approximately 1000 to over 15,000 individuals, with the highest coverage observed among ANMs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMain Findings (CHWs)\u003c/h3\u003e\n\u003cp\u003eKey findings from each category, organized using L\u0026eacute;vesque conceptual framework, \u003csup\u003e11\u003c/sup\u003e are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e [insert Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategorization Matrix with Categories, Codes and # References for CHWs (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode (# references)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCode (# references)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCode (# references)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApproachability\u003c/b\u003e \u0026ndash; How CHWs help community members identify and utilize health services and impact well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTransparency (22) \u0026ndash;\u003c/b\u003e CHW\u0026rsquo;s ability to disclose information accurately \u0026ndash; both positive and negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eInformation sharing (22)\u003c/b\u003e\u0026ndash; CHW\u0026rsquo;s ability to provide timely access to information- community health literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTrust/respect (67)\u0026ndash;\u003c/b\u003e CHW\u0026rsquo;s ability to obtain trust and respect from community members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcceptability-\u003c/b\u003e Cultural and societal factors- if aspects of services are acceptable \u0026amp; appropriate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eProfessional Values (96)\u003c/b\u003e \u0026ndash; How CHWs view roles, positive \u0026amp; negative aspects of role, salary \u0026amp; benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNorms, Culture \u0026amp; Family (64)\u003c/b\u003e How culture, society and family create barriers or facilitators for role acceptance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMotivations for becoming a CHW (31)\u003c/b\u003e Reasons or what prompted them to become a CHW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAvailability \u0026amp; Accommodation\u003c/b\u003e \u0026ndash; Physical space and if CHWs can be reached in a timely manner,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCommunity Needs (41)\u003c/b\u003e Services/health needs needed for their community that are and/or not available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCOVID-19 Impacts (125) \u0026ndash;\u003c/b\u003e Impacts of the pandemic- both positive \u0026amp; negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLogistical (3)\u003c/b\u003e \u0026ndash; Travel time to clinic, opening hours, flexibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAffordability\u003c/b\u003e Cost of services and related expenses, loss of income, travel time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFinancial Constraints (12)\u003c/b\u003e Unable to access private hospital or care and must rely on community/gov\u0026rsquo;t services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo Financial Constraints\u003c/b\u003e Able to afford private care if warranted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppropriateness \u0026ndash;\u003c/b\u003e Fit between services provided and patient needs, time spent assessing health problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQuality of Care provided (182)-\u003c/b\u003e Training received, struggles with day-to-day operations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEmpowerment \u0026amp; Advocacy (22)\u003c/b\u003e Advocating for the community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eApproachability\u003c/h3\u003e\n\u003cp\u003eApproachability was closely tied to the level of trust and respect that CHWs established within their communities. Participants consistently described how familiarity, accessibility, and mutual respect shaped their ability to reach community members and influence health-seeking behaviours. Community members often felt comfortable approaching CHWs directly, even visiting their homes when other means of contact were unavailable. As ASHA1 explained, \u0026ldquo;\u003cem\u003eIf they don\u0026rsquo;t have a phone or if they can\u0026rsquo;t find me on the way, they come to my house.\u0026rdquo;\u003c/em\u003e Respect emerged as both a motivator and reward for their work. Several participants noted that their work was not driven by financial incentives but by community recognition: \u0026ldquo;\u003cem\u003eWe work for respect only\u003c/em\u003e\u0026rdquo; (ASHA1). Over time, sustained interactions fostered deep familiarity and trust, with one participant (AWW3) reflecting that, \u0026ldquo;\u003cem\u003ePeople have become more confident about us. In the initial years of my work as AWW, people did not trust us\u0026hellip; but now people trust us and they send their kids.\u0026rdquo;\u003c/em\u003e This evolution of trust illustrates how repeated contact and demonstrated reliability transformed relationships from tentative to familial, as one participant described, \u003cem\u003e\u0026ldquo;If you come to the same place, it becomes like a family. The people living in the area feel that they belong to the same family\u003c/em\u003e\u0026rdquo; (AWW2).\u003c/p\u003e \u003cp\u003eParticipant\u0026rsquo;s ethical conduct further reinforced trust and credibility. Several participants emphasized that they refused gifts or money from community members, perceiving such gestures as threats to their professional integrity. \u003cem\u003e\u0026ldquo;We don\u0026rsquo;t accept anything from people,\u0026rdquo;\u003c/em\u003e ANM2 explained, \u0026ldquo;\u003cem\u003eIf they want to give us sweets, we take half a piece or one piece, not more than that.\u0026rdquo;\u003c/em\u003e This moral restraint strengthened the perception of CHWs as honest and dependable, which also, enhanced their approachability. For many community members, CHWs were seen as trusted intermediaries between the community and formal healthcare providers. As ASHA5 noted, \u0026ldquo;\u003cem\u003eIf you go there, no matter how big a doctor you are, they won\u0026rsquo;t let you in their house, but if you go there with us, people will let you in\u0026hellip; they trust us a lot.\u0026rdquo;\u003c/em\u003e However, some participants also acknowledged that approachability was not universal; some individuals preferred to seek care elsewhere or were less open to engagement. As ASHA4 noted: \u003cem\u003e\u0026ldquo;\u0026hellip; some people don\u0026rsquo;t want to talk to us because they go to the private clinic/hospitals\u0026rdquo;.\u003c/em\u003e Nonetheless, the overall pattern underscored that trust and respect were central to making services visible, approachable, and acceptable within the community.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAcceptability\u003c/h2\u003e \u003cp\u003eAcceptability reflected how CHWs negotiated the alignment between their professional identity, community expectations, and cultural norms. Two interrelated codes, professional values and norms, culture, and family shaped how CHWs\u0026rsquo; roles were perceived and accepted within their communities.\u003c/p\u003e \u003cp\u003eSeveral participants expressed a deep sense of purpose and pride in their work, viewing it as meaningful and socially valuable despite limited financial recognition and heavy workloads. Some emphasized intrinsic motivation and moral commitment to serving others, as ASHA1 explained, \u003cem\u003e\u0026ldquo;I like my work and I would go to any extent to do my work.\u0026rdquo;\u003c/em\u003e Others described the satisfaction of helping people across the lifespan, \u0026ldquo;\u003cem\u003eIt feels good to save a child, it feels good to save a child after immunization, it feels very good\u0026rdquo;\u003c/em\u003e (ASHA5). While most participants acknowledged that their workload had increased since the COVID-19 pandemic, particularly from digital reporting, many continued to display perseverance and adaptability. \u003cem\u003e\u0026ldquo;If there is a demand for some work and I don\u0026rsquo;t know how to do it, then I can learn it and do that work,\u0026rdquo;\u003c/em\u003e ASHA2 remarked, highlighting the commitment to ongoing learning despite limited resources.\u003c/p\u003e \u003cp\u003e Participants also reflected on how social perceptions affected the acceptability of their role, noting that community members viewed their work as less important than that of doctors or facility-based staff. Nevertheless, many still asserted the dignity and value of their work: \u0026ldquo;\u003cem\u003eMany people think that our work is not good\u0026hellip; but we don\u0026rsquo;t think that we do small or big work\u0026rdquo;\u003c/em\u003e (ASHA1). This professional pride and resilience reinforced their credibility and community trust, despite structural challenges such as low pay and poor technological infrastructure.\u003c/p\u003e \u003cp\u003eAcceptability was also shaped by sociocultural and familial influences. Several participants faced opposition from family members, particularly mothers-in-law, who prioritized domestic responsibilities over paid work. As ASHA1 shared, \u0026ldquo;\u003cem\u003eMy husband supports me a lot but my mother-in-law told me not to do it\u0026hellip; when I go home, I feel like I am being insulted by them\u003c/em\u003e.\u0026rdquo; Another added, \u0026ldquo;\u003cem\u003eMy mother-in-law doesn\u0026rsquo;t like it. She has conservative thinking\u0026rdquo;\u003c/em\u003e (ASHA2). These accounts highlight how traditional gender norms can limit women\u0026rsquo;s autonomy and the perceived legitimacy of their professional roles. However, others described supportive family environments that enabled them to thrive in their positions, as ANM1explained, \u003cem\u003e\u0026ldquo;My brother-in-law supported me a lot\u0026hellip; he agreed for my training as a CHW.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eCultural norms also influenced the scope of CHWs\u0026rsquo; interactions within communities. Several noted that male community members were less likely to engage with them directly, as \u003cem\u003e\u0026ldquo;mostly women talk to us; males usually don\u0026rsquo;t talk to us\u0026rdquo;\u003c/em\u003e (AWW4). These gendered communication patterns constrained the reach of health promotion activities, particularly those involving men\u0026rsquo;s health. Overall, the acceptability of CHWs\u0026rsquo; work was strengthened by their ethical commitment, adaptability, and community-centred values, but was simultaneously challenged by gender and cultural norms. The intersection of professional pride and sociocultural expectations revealed that CHWs\u0026rsquo; acceptability is not static but continuously negotiated within the social and cultural contexts in which they work.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAvailability \u0026amp; Accommodation\u003c/h2\u003e \u003cp\u003eThis dimension reflects the accessibility of healthcare resources, and the extent to which CHWs could reach and serve communities in a timely and efficient manner. Participants described how the COVID-19 pandemic influenced the availability of essential supplies, service delivery, and their ability to safely interact with community members. During the initial phase of the pandemic, participants reported widespread shortages of masks, sanitizers, and gloves, often purchasing these items themselves. Despite inconsistent provision of protective equipment and delays in remuneration, they continued their duties, specifically when conducting household visits, distributing nutrient supplements and medicine, and assisting with COVID-19 surveillance. ASHA5 explained, \u003cem\u003e\u0026ldquo;We were buying sanitizers with our own money in the initial days of COVID, but after two or four months, we started to get masks and gloves.\u0026rdquo;\u003c/em\u003e Another noted, \u003cem\u003e\u0026ldquo;Sometimes we were getting masks and sanitizers and sometimes not, but the work didn\u0026rsquo;t stop\u0026rdquo; (ASHA2).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe pandemic also catalyzed new modes of working and communication. Several described a shift toward digital reporting and mobile-based data sharing, which improved timeliness and oversight despite challenges. As ASHA1 reflected, \u003cem\u003e\u0026ldquo;Earlier, I used to give oral contraceptives and condoms to houses, but now I go to their house and provide family planning information online immediately on our phone.\u0026rdquo;\u003c/em\u003e However, fears of contagion, transportation barriers, and increased workloads exacerbated stress and fatigue, highlighting the fragility of service delivery during crises.\u003c/p\u003e \u003cp\u003eBeyond the pandemic, participants identified persistent infrastructure and resource constraints that limited their ability to meet community needs. Many described health centres as under-resourced and overcrowded, with insufficient equipment, space, and basic furnishings. One participant noted, \u003cem\u003e\u0026ldquo;Right now, we are very worried about the chairs in the center. There are no chairs\u0026mdash;we work standing up\u0026rdquo;\u003c/em\u003e (ASHA2). Another added, \u003cem\u003e\u0026ldquo;This is a small dispensary\u0026hellip; we can treat minor illnesses, not major ones. Our staff don\u0026rsquo;t have enough resources or training for that\u0026rdquo;\u003c/em\u003e (ANM1). Participants also emphasized the need for expanded services such as maternal care, diagnostic facilities, and health information for children.\u003c/p\u003e \u003cp\u003eAt the community level, mistrust of government facilities and low health literacy affected service utilization. As AWW3 observed, \u003cem\u003e\u0026ldquo;People in this area are so illiterate. If anyone gives anything to them for free, they will come in bulk, but if anyone gives them health advice, they may not come at all.\u0026rdquo;\u003c/em\u003e Despite these barriers, participants continued to act as vital intermediaries, bridging service gaps, counselling families, and fostering trust between communities and the formal health system.\u003c/p\u003e \u003cp\u003eOverall, findings highlight that while CHWs remained steadfast in their commitment to service, their effectiveness was often constrained by inadequate physical resources, insufficient institutional support, and uneven mechanisms during and after the COVID-19 pandemic. This underscores the need for sustained investments in basic infrastructure, digital tools, and responsive management systems to ensure that CHWs can accommodate and respond effectively to community health needs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAffordability\u003c/h2\u003e \u003cp\u003eAffordability, which relates to healthcare costs, lost income and time required for travel to access care, emerged as a key determinant of healthcare access, reflecting the interplay between economic vulnerability, indirect healthcare costs, and reliance on daily wages. Participants described their catchment populations as predominantly poor, with most households depending on unstable employment. Women were often unemployed or working as domestic helpers, while men engaged in low-income private jobs such as painting or construction, earning approximately Rupees 15,000\u0026ndash;20,000 per month. As AWW1 noted, \u003cem\u003e\u0026ldquo;Most of them are poor\u0026mdash;most rely on daily wages. In my area, there are hardly two to four working women, and those who work are maids doing cleaning and cooking in people\u0026rsquo;s houses.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eLimited and inconsistent income left families with little capacity to absorb healthcare-related expenses, including transportation, loss of wages, and purchasing medication. Although government health facilities provided free or low-cost services, indirect costs continued to impede access. One ASHA4 explained, \u003cem\u003e\u0026ldquo;Some people are poor and they cannot afford these facilities from outside easily due to their financial conditions\u0026rdquo;.\u003c/em\u003e Participants emphasized that poverty also influenced healthcare-seeking behaviour, with many preferring local centres over private clinics due to affordability. They frequently identified and assisted vulnerable households, such as widows, the unemployed, and people with disabilities, in accessing government welfare schemes, yet noted that social assistance was often insufficient. The financial strain of the COVID-19 pandemic further compounded these challenges, as reflected by ASHA3, \u003cem\u003e\u0026ldquo;Financially, everyone had a problem at that time, no matter how much one earned\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOverall, participants\u0026rsquo; accounts highlight how economic hardship and indirect healthcare costs continue to shape health-seeking behaviours and limit service utilization. Their experiences support the need for sustained financial protection measures, strengthened welfare linkages, and flexible service delivery models that minimize costs for marginalized families.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAppropriateness \u0026amp; Advocacy\u003c/h2\u003e \u003cp\u003eAppropriateness refers to the degree of fit between the services provided and the needs of the population, including timeliness and quality of care, and the ability of CHWs to spend sufficient time assessing and addressing health concerns. Participants provided a broad range of health services aligned with the needs of their communities, including vaccination, early childhood education, antenatal and postnatal care, assistance with family planning and distribution of nutrient supplements. Participants routinely adapted their work to meet community expectations, often working beyond regular hours to ensure continuity of care. One participant shared, \u003cem\u003e\u0026ldquo;We don\u0026rsquo;t have any fixed holiday\u0026hellip; if there\u0026rsquo;s a woman\u0026rsquo;s delivery case, we have to go on Sundays too with that lady to the hospital. We have to wait for the entire day in the hospital\u0026rdquo;\u003c/em\u003e (ASHA1).\u003c/p\u003e \u003cp\u003eThe increasing workload and expectations from supervisors also contributed to work intensification, yet CHWs continued to demonstrate commitment to timely and responsive service delivery. As one noted, \u003cem\u003e\u0026ldquo;The number of patients are increasing\u0026hellip; they ask that please give us a report on Sunday as well. You have to do a survey, you have to do it right now\u0026rdquo;\u003c/em\u003e (ASHA1). Participants highlighted that while basic services and medicines were generally available, some diagnostic and maternal services remained limited, requiring referrals to external facilities: \u003cem\u003e\u0026ldquo;People can get free blood and urine tests here, everything is available here but ultrasound, X-rays and delivery for pregnant ladies have to be done from outside\u0026rdquo;\u003c/em\u003e (ASHA5). Despite these challenges, participants emphasized the value of ongoing training to improve their competencies and service quality. As expressed by ANM3, \u003cem\u003e\u0026ldquo;We get training for everything\u0026mdash;family planning, NCDs, and safe immunization. We get training once or twice a month\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eParticipants also positioned themselves as advocates, particularly for the elderly, women, and low-income families. Their advocacy often extends beyond health to include social entitlements and community well-being. One participant noted, \u003cem\u003e\u0026ldquo;A lot of women tell me that they haven\u0026rsquo;t received their old age pension, so I tell them to go to the MLA office\u0026hellip; we motivate them to apply for old age pension\u0026rdquo;\u003c/em\u003e (AWW2).\u003c/p\u003e \u003cp\u003eParticipants expressed personal satisfaction in empowering beneficiaries with knowledge and access to care. As ANM2 described, \u003cem\u003e\u0026ldquo;The poor population in this area doesn\u0026rsquo;t know what diet to take\u0026hellip; so sometimes women get miscarriages or don\u0026rsquo;t know how to give birth properly. We guide them at that time and ensure that they don\u0026rsquo;t have any problem\u0026rdquo;\u003c/em\u003e. Similarly, ASHA4 emphasized engaging men in family planning to alleviate the reproductive burden on women: \u003cem\u003e\u0026ldquo;We give more knowledge to the male members of the family to motivate them to go for male family planning operations so that the ladies don\u0026rsquo;t have to face so many problems.\u0026rdquo;\u003c/em\u003e These findings underscore the CHWs\u0026rsquo; dual role as both healthcare providers and social advocates. Their work reflects a commitment to equity and empowerment of their communities, highlighting their integral role in bridging the gap between the health system and vulnerable populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Demographics: Beneficiaries \u0026amp; Community Leaders\u003c/h2\u003e \u003cp\u003eA total of five beneficiaries and four community leaders participated in the interviews. All community leaders were male, while only one beneficiary identified as male. Beneficiaries ranged in age from 31\u0026ndash;45 years and community leaders from 40\u0026ndash;65 years, with a combined mean age of 42.66 years. All participants were married, and one beneficiary was pregnant at the time of the interview. Most beneficiaries had no formal education and, aside from one individual, were homemakers; only two out of five beneficiaries lived in rural areas. In contrast, most community leaders had completed university education and resided in urban communities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMain Findings: Beneficiaries and Community Leaders\u003c/h2\u003e \u003cp\u003eFor the beneficiaries and community leaders, we applied the complementary user-side dimensions of the L\u0026eacute;vesque framework,\u003csup\u003e11\u003c/sup\u003e which describe the abilities required to access care: (1) ability to perceive, (2) ability to seek, (3) ability to reach, (4) ability to pay, and (5) ability to engage. A categorization matrix was similarly developed to align these abilities with relevant codes and reference frequencies (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)[insert Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]. The three most prominent categories: ability to perceive, ability to reach, and ability to engage, accounted for most coded references. Therefore, our description highlights these key abilities, as they most clearly illustrate how participants experienced and navigated access to healthcare in relation to CHW roles.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategorization Matrix with Categories, Codes and # References for Beneficiaries (n\u0026thinsp;=\u0026thinsp;5) \u0026amp; Community Leaders (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCode (#references)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCode (#references)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCode (#references)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbility to perceive-\u003c/b\u003e an individual\u0026rsquo;s health literacy, health beliefs, trust and expectation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTransparency\u003c/b\u003e (2)- CHW\u0026rsquo;s ability to disclose information accurately- both positive and negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eInformation Sharing\u003c/b\u003e (6) CHW\u0026rsquo;s ability to provide timely access to information, ensures health literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTrust/respect\u003c/b\u003e (13) CHW\u0026rsquo;s ability to obtain trust and respect from community members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbility to seek-\u003c/b\u003e personal and social values, culture, gender \u0026amp; autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eProfessional Values\u003c/b\u003e (6)- how CHW\u0026rsquo;s roles are perceived\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNorms Culture \u0026amp; Family\u003c/b\u003e (4), How culture, society and their family create barriers and facilitators for\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMotivations for becoming a CHW\u003c/b\u003e (0) what community perceive as the motivation for this role\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbility to reach-\u003c/b\u003e living environments, mobility and social supports\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCommunity Needs\u003c/b\u003e (17) services and health needs of the community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCOVID-19 Impact\u003c/b\u003e (20) Impacts of the pandemic, both positive \u0026amp; negative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eLogistical\u003c/b\u003e (4) Travel time to clinic, flexibility in hours of operation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbility to pay-\u003c/b\u003e income, assets and health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFinancial Constraints\u003c/b\u003e (3) unable to access private hospitals and must rely on community/gov\u0026rsquo;t services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo financial Constraints\u003c/b\u003e (0)\u0026ndash; Able to afford private care if warranted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAbility to engage-\u003c/b\u003e empowerment, information adherence and caregiver support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQuality of Care Provided\u003c/b\u003e (23) CHW\u0026rsquo;s training, competency,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEmpowerment \u0026amp; Advocacy\u003c/b\u003e (1) \u0026ndash; How CHWs empower and advocate for their community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAbility to Perceive: How beneficiaries and community leaders understand and interpret their need for care and the role of CHWs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; ability to recognize their health needs and identify where to seek care was strongly shaped by their perceptions of CHWs as approachable, trustworthy, and deeply embedded within the community. Many beneficiaries described relying on CHWs for guidance, often consulting them alongside family members and doctors when health concerns arose. As one beneficiary explained, \u003cem\u003e\u0026ldquo;We consult with the family members and the doctors and CHWs in this center who come our home and meet us\u0026rdquo;\u003c/em\u003e (B2). Another noted that the increased visibility of CHWs over time improved community awareness of available services: \u003cem\u003e\u0026ldquo;Nobody [ASHA] came to my house to tell anything about delivery\u0026hellip; but now the situation has changed. Now ASHA workers come and give advice to people, yes, they talk nicely\u0026rdquo;\u003c/em\u003e (B4).\u003c/p\u003e \u003cp\u003eTrust in CHWs was a recurring theme that reinforced participants\u0026rsquo; confidence in recognizing when care was needed. Beneficiaries repeatedly emphasized this trust, stating, \u003cem\u003e\u0026ldquo;I have faith in them and their services\u0026rdquo;\u003c/em\u003e (B1), and \u003cem\u003e\u0026ldquo;Yes, we do respect them\u0026rdquo;\u003c/em\u003e (B2). Community leaders echoed this sentiment, confirming that \u003cem\u003e\u0026ldquo;people respect CHWs\u0026rdquo;\u003c/em\u003e and that individuals frequently relied on them for advice, noting that \u003cem\u003e\u0026ldquo;people have ASHA worker\u0026rsquo;s phone numbers\u0026hellip; [and] can call them anytime for any health-related problems\u0026rdquo;\u003c/em\u003e (B3; C1).\u003c/p\u003e \u003cp\u003eFamiliarity and shared community identity further strengthened participants\u0026rsquo; perceptions of CHWs as credible and accessible sources of information. Community leaders highlighted that CHWs\u0026rsquo; embeddedness within the community increased comfort and trust: \u003cem\u003e\u0026ldquo;Mostly CHWs are local people of this area\u0026hellip; they know each and every house of their population, so people feel comfortable with them\u0026rdquo;\u003c/em\u003e (C2). Another added, \u003cem\u003e\u0026ldquo;People are very comfortable with CHWs\u0026hellip; they are part of this community only\u0026rdquo;\u003c/em\u003e (C3). Their involvement in tasks beyond health, such as distributing election cards or updating voting lists, also reinforced their legitimacy and visibility within local structures.\u003c/p\u003e \u003cp\u003eThese perceptions were amplified during the COVID-19 pandemic, when CHWs took on heightened roles in helping, providing information, and support under difficult circumstances. One community leader described how their commitment reshaped public awareness of their value: \u003cem\u003e\u0026ldquo;CHWs were valued so much in COVID time\u0026hellip; they were valued more than doctors and people respected them as \u0026lsquo;God\u0026rsquo; during COVID\u0026rdquo;\u003c/em\u003e (C4). Their advice was trusted and closely followed, as reflected in the observation that \u003cem\u003e\u0026ldquo;If any CHW said\u0026hellip; you have to stay quarantined for 14 days, community people were listening\u0026hellip; and following carefully\u0026rdquo;\u003c/em\u003e (C4).\u003c/p\u003e \u003cp\u003eCollectively, these narratives show that beneficiaries\u0026rsquo; and community leaders\u0026rsquo; ability to perceive health needs was facilitated by strong trust, familiarity, and comfort with CHWs, who served as credible and accessible sources of health information and awareness.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAbility to Reach\u003c/b\u003e \u0026ndash; \u003cb\u003eHow Beneficiaries lived, travelled to healthcare facilities and social supports\u003c/b\u003e\u003c/p\u003e \u003cp\u003eParticipants identified several factors that shaped their ability to physically access healthcare services, including infrastructure limitations, time and travel burdens and the extensive disruptions from the COVID-19 pandemic. Many beneficiaries highlighted the challenges posed by limited diagnostic and facility resources at the health centre. As B5 explained, although routine care was available, \u003cem\u003e\u0026ldquo;these machines for ultrasounds and X-rays should be available\u0026hellip; if they had these machines, we wouldn\u0026rsquo;t have had any problem\u0026rdquo;\u003c/em\u003e (B3). Pregnant women were particularly affected, with one beneficiary noting that \u003cem\u003e\u0026ldquo;ultrasound and X-ray facilities are not available here\u0026hellip; we have to get these services from outside, and that becomes very difficult\u0026rdquo;\u003c/em\u003e. Basic infrastructure deficiencies, such as the absence of drinking water and poor sanitation, also constrained accessibility, with participants describing the beneficiary toilets as \u003cem\u003e\u0026ldquo;too dirty\u0026hellip; there is no water\u0026rdquo;\u003c/em\u003e (B5).\u003c/p\u003e \u003cp\u003eTravel and time burdens further limited individuals\u0026rsquo; ability to reach care. Participants described the inconvenience and long travel times required for off-site diagnostics, stating, \u003cem\u003e\u0026ldquo;we have to go to the hospital every month\u0026hellip; it takes a lot of time\u0026rdquo;\u003c/em\u003e (B3). Health centre operating hours also did not align with the schedules of working adults and school-aged children. Several recommended extended hours to increase access, explaining that \u003cem\u003e\u0026ldquo;all the men and women are doing work, no one can come here in the morning\u0026rdquo;\u003c/em\u003e and that children were also unable to attend during school hours (B1). Another participant emphasized that evening availability \u003cem\u003e\u0026ldquo;would benefit people who have to go to work in the morning\u0026rdquo;\u003c/em\u003e (B2).\u003c/p\u003e \u003cp\u003eParticipants also described environmental and occupational factors that shaped access needs. Community leaders reported a history of respiratory and occupational health problems in areas with high exposure to dust and pollution, noting that \u003cem\u003e\u0026ldquo;there were a lot of health problems\u0026hellip; because the population was involved in labour work\u0026rdquo;\u003c/em\u003e (CL1). Others highlighted the burden of chronic conditions, explaining that \u003cem\u003e\u0026ldquo;most people have diabetes and blood pressure\u0026hellip; people are alcohol addicted\u0026rdquo;\u003c/em\u003e (CL4), further increasing the community\u0026rsquo;s need to reach regular care.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic significantly disrupted physical access to services. Many experienced severe financial strains from job loss, with B1 explaining that it became \u003cem\u003e\u0026ldquo;very difficult to eat and drink at home due to poor financial conditions\u0026hellip; my husband\u0026rsquo;s work was closed\u0026rdquo;\u003c/em\u003e. Lockdowns restricted movement, and some described not leaving their homes at all: \u003cem\u003e\u0026ldquo;I never used to go out of the house\u0026hellip; everything was closed\u0026rdquo;\u003c/em\u003e (B3). Community leaders also described resource shortages and widespread hardship, including \u003cem\u003e\u0026ldquo;shortage of oxygen cylinders\u0026rdquo;\u003c/em\u003e and difficulties accessing hospital care (CL2). Yet, community support networks partly mitigated these barriers, as leaders explained that \u003cem\u003e\u0026ldquo;if someone needed food or medicines, we provided help\u0026rdquo;\u003c/em\u003e (CL1).\u003c/p\u003e \u003cp\u003eOverall, participants\u0026rsquo; ability to reach healthcare was shaped by a combination of structural, environmental, and pandemic-related constraints, compounded by inconsistent facility resources and challenging socio-economic conditions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAbility to Engage- How Well Beneficiaries Feel Informed, Empowered and Supported by Caregivers and Able to Follow Recommended Care\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Participants described high levels of engagement with CHWs, facilitated by outreach, positive interpersonal interactions, and a strong sense of trust and familiarity within the community. Many beneficiaries explained that their initial connection to the health centre was established through CHW home visits. One beneficiary described how engagement began when \u003cem\u003e\u0026ldquo;ASHA sister came to our house\u0026hellip; she used to tell me about the treatment and medicines\u0026rdquo;\u003c/em\u003e (B2). Such outreach was also emphasized by community leaders, who noted that CHWs \u003cem\u003e\u0026ldquo;visit each and every home\u0026hellip; give medicines and vaccinations to the children and pregnant ladies\u0026rdquo;\u003c/em\u003e (CL2).\u003c/p\u003e \u003cp\u003eInterpersonal relationships and respectful communication played an important role in supporting engagement with services. Beneficiaries frequently described positive experiences, stating, for example, \u003cem\u003e\u0026ldquo;everyone is good here, they behave very well with their patients. I feel good about it\u0026rdquo;\u003c/em\u003e (B3). Similarly, community leaders highlighted widespread satisfaction, explaining that \u003cem\u003e\u0026ldquo;people are happy with their work\u0026hellip; CHWs are working really hard for improving people\u0026rsquo;s health\u0026rdquo;\u003c/em\u003e (CL2).\u003c/p\u003e \u003cp\u003eParticipants also described how engagement varied depending on the perceived severity of illness. One beneficiary explained that she typically used the centre for minor issues, stating, \u003cem\u003e\u0026ldquo;If there is big illness I go to private clinic or hospital, but if there is small problem like cold and cough I prefer to come to this center\u0026rdquo;\u003c/em\u003e (B4). This pattern reflected CHWs\u0026rsquo; roles in facilitating ongoing, low-acuity care while more severe conditions were seen as requiring external services.\u003c/p\u003e \u003cp\u003eDespite strong engagement, participants identified several structural barriers that limited CHWs\u0026rsquo; ability to support sustained care. Some beneficiaries emphasized the need for improved training and resources, suggesting that CHWs should \u003cem\u003e\u0026ldquo;tell people to come after a week when resources would be available\u0026rdquo;\u003c/em\u003e if supplies were lacking (B2). Community leaders similarly noted gaps in training and system capacity, stating that \u003cem\u003e\u0026ldquo;If they get more training, it would be better\u0026hellip; more than training, emergency health care services in health centres are important\u0026rdquo;\u003c/em\u003e (CL3). Low salaries and high workloads especially for ASHAs were also cited as major constraints, with leaders observing that CHWs \u003cem\u003e\u0026ldquo;have been given a lot of workload\u0026rdquo;\u003c/em\u003e and that their \u003cem\u003e\u0026ldquo;salary should be increased\u0026rdquo;\u003c/em\u003e (CL4).\u003c/p\u003e \u003cp\u003eEngagement was also shaped by ongoing collaboration between CHWs and community leaders. Leaders routinely interacted with CHWs for tasks such as document verification, describing CHWs as \u003cem\u003e\u0026ldquo;active\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;working very well\u0026rdquo;\u003c/em\u003e (CL1). These interactions strengthened relationships and reinforced community confidence in CHWs.\u003c/p\u003e \u003cp\u003eOverall, participants described a supportive and trusting environment where CHWs played a central role in facilitating engagement with the health system. However, sustained engagement was challenged by systemic issues including inadequate resources, limited training and heavy workloads.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis qualitative descriptive study aimed at developing an in-depth understanding of CHW\u0026rsquo;s roles, routines, successes and challenges, contributions, and motivations as they delivered care in rural and urban communities in Delhi, India during and after the COVID-19 pandemic. We also explored how their roles were perceived and accepted by beneficiaries and community leaders. To guide this work, we applied the L\u0026eacute;vesque conceptual framework.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur findings highlight the central role of approachability, trust and respect in the effectiveness of CHWs in both rural and urban settings. Consistent with prior research,\u003csup\u003e24,25\u003c/sup\u003e CHWs\u0026rsquo; familiarity, accessibility, and ethical conduct were critical in fostering trust and credibility within their communities, enabling them to influence health-seeking behaviours effectively. Our findings also suggest that recognition and respect, rather than financial renumeration alone, serve as powerful motivators for CHWs, particularly for ASHAs, who consistently emphasized the value of social appreciation in sustaining their commitment to their roles and increasing workloads. This aligns with other research demonstrating that CHWs often derive a strong sense of role identity, duty and purpose from community validation, especially when remuneration is limited or inconsistent. Studies in Nepal,\u003csup\u003e26\u003c/sup\u003e Ethiopia,\u003csup\u003e27\u003c/sup\u003e and Kenya,\u003csup\u003e28\u003c/sup\u003e where volunteer or minimally compensated CHWs form the backbone of primary care delivery, showed similar results. In these studies, non-financial motivators such as social status, trust, and community gratitude partially compensated for lack of pay; however, such recognition does not replace the need for fair and reliable compensation. This complexity was especially apparent among the ASHA participants, who receive the lowest fixed income among the three CHW cadres (i.e., 3000 INR (~\u003cspan\u003e$\u003c/span\u003e33 USD) per month) and therefore relied heavily on task-based incentives to supplement their earnings. For instance, ASHAs receive additional compensation when a child is vaccinated or when a woman delivers in a healthcare facility. This structure places them in a position where the distinction between \u0026ldquo;working harder\u0026rdquo; out of financial necessity versus intrinsic motivation becomes difficult to disentangle. While many expressed a genuine desire to help their community, the incentive-based structure raises questions about whether increased effort is driven by commitment to community health, financial pressure, or both.\u003c/p\u003e \u003cp\u003eCommunity leaders also highlighted the disparity between CHWs\u0026rsquo; heavy workloads and their limited pay, reinforcing concerns that inadequate remuneration contributes to stress, role strain, and long-term sustainability. Whether CHWs should work as volunteers or be compensated remains a point of debate; however evidence suggests that volunteerism is difficult to sustain over long periods, particularly in low to middle income countries like India where many CHWs experience financial insecurity and rely on this work for income.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Although many CHW programs are designed with the expectation that workers spend only a small portion of their time on health-related duties, community needs often demand full-time engagement. \u003csup\u003e24\u003c/sup\u003e In our study, ASHA workers receive higher pay for task-based activities, creating tension between the expectation of part-time work and the pressures to take on additional tasks to increase earnings. This mismatch between workload, compensation, and community expectations underscores the need to reconsider remuneration models to support both CHW well-being and program sustainability.\u003c/p\u003e \u003cp\u003eIn our study, several CHWs also described experiencing tension with family members, especially mothers-in-law who discouraged their role. This conflict highlights a deeper struggle between role identify and prevailing sociocultural expectations especially with respect to gender-based norms and roles. Such dynamics however are not unique to our study. Research from other low to middle income countries has also documented similar challenges. In a systematic review and qualitative meta-analysis of 38 studies on the sociocultural factors impacting CHWs in South Asia, the authors found that CHWs regularly faced challenges due to religious and cultural norms, gender and generational issues. \u003csup\u003e29\u003c/sup\u003e Our findings suggest that programmatic efforts to support CHWs must go beyond training and remuneration, but engaging family systems and fostering sociocultural legitimacy for the CHW role may be just as important for sustainability. While in high-income settings the precise nature of these conflicts may differ, similar tensions around professional commitment versus family and community expectations can still arise, particularly in settings where CHWs come from marginalized or close-knit communities. For example, a Canadian study examining Indigenous CHWs in remote northern communities found that workers often experienced intense pressure and expectations from community members, many of whom were relatives.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e These communities, often characterized by small populations where \u0026ldquo;everyone knows everyone\u0026rdquo;, created additional challenges. One major concern centred around confidentiality: some community members felt uncomfortable sharing personal health information with CHWs for fear that it might not remain private.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Unlike the more populous and diverse settings in India, these small northern communities amplify the social and cultural proximity between CHWs and residents, shaping both the expectations placed on CHWs and the relational complexities of their work.\u003c/p\u003e \u003cp\u003eFinally, the COVID-19 pandemic introduced profound complexities for CHWs and their communities. Participants described a dramatic increase in workload alongside a rapid shift toward digital technologies for surveillance, reporting and communication. Many struggled with basic tools like phones that malfunctioned, unreliable network connectivity, and unfamiliar apps, highlighting the digital divide that remains prevalent today. These challenges were further compounded by longstanding resource shortages, including limited access to clean water, sanitation, and essential supplies all of which were magnified during the pandemic. Importantly, because CHWs are positioned at the frontline, community frustrations with systemic inadequacies were often directed toward them despite these issues being beyond their control. Similar patterns were documented globally, even in high income countries, nurses and other frontline providers faced parallel struggles with rapidly evolving technology demands, insufficient equipment, and overwhelming workloads.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Taken together, these findings reinforce that pandemic related strains were not unique to CHWs in India but part of a broader, international pattern of health system vulnerability.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study provides an in-depth understanding of how CHWs navigate complex community needs and integrate healthcare within constrained environments. A particular strength is the rich contextual insights from close collaboration with the local interviewer and observational field notes, which helped anchor the findings despite that some of the research team was not present in India during data collection. However, this absence is also a limitation, as is the study\u0026rsquo;s focus on one geographic region and specific mix of participants, which may limit transferability to other contexts. Additionally, as with all qualitative studies, the findings reflect interpretation within a defined methodology and may not capture the full breadth of CHW experiences across India\u0026rsquo;s diverse sociocultural landscape.\u003c/p\u003e \u003cp\u003eNevertheless, the study highlights areas for future research, including the need to better understand sociocultural influences on CHWs\u0026rsquo; professional identities, sustainability of incentive-based remuneration models, and the long-term impacts of digital technologies. Strengthening CHW programs will require sustained attention to fair compensation, ongoing training (including digital literacy), supportive supervision, and engagement with families and communities to reduce sociocultural tensions. Investing in these supports will not only enhance CHW well-being and performance but also bolster the critical role they play in advancing equitable, community-centred healthcare globally.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAuxiliary Nurse Midwives\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASHAs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccredited Social Health Activists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAWWs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnganwadi Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Health Worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandards for Reporting Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003equalitative content analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003e This study received ethical approval from Dalhousie University, Nova Scotia, Canada (REB # 2024\u0026thinsp;\u0026minus;\u0026thinsp;744) and from Jamia Hamdard University, New Delhi, India (Ref. No. 12/24 (12/11/2024). All participants provided written, informed consent. The study was conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2) and the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e Funding for this study has been made possible by a peer reviewed, Research Nova Scotia, 2024-25 International Nursing Research Program Award.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors read and approved the final manuscript. SR, SS and FK were primarily responsible for recruitment and consenting of participants, data collection, reviewing transcribed/translated transcripts, obtaining field notes and reviewing the data analysis. AI provided insights into the data analysis, presentation of the results and discussion. ND was responsible for final editing of the manuscript, references and supplementary material. AS was the primary investigator of the study, analyzed the data, wrote the manuscript and collaborated with the research team for feedback, edits and final submission.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePeretz PJ, Islam N, Matiz LA. Community Health Workers and COVID-19- Addressing Social Determinants of Health in Times of Crisis and Beyond. N Engl J Med. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMp2022641\u003c/span\u003e\u003cspan address=\"10.1056/NEJMp2022641\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhelan H, Yates V, Lillie E. Challenges in healthcare delivery in low-and-middle- income countries. Anaesth Intensive Care Med. 2022;23(8):501\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalcazar H, Rosenthal L, Brownstein JN, Rush CH, Matos S, Hernandez L. Community health workers can be a public health force for change in the United States: three actions for a new paradigm. Am J Public Health. 2011;101(12):2199\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry HB, Zulliger R, Rogers MM. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness. Annu Rev Public Health. 2014;35:399\u0026ndash;421.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCHW training. 15 Community Health Worker Job Titles and Different Roles [Internet]. [cited 2025 Nov9]. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://chwtraining.org/15-community-health-worker-job-titles-and-different-roles/\u003c/span\u003e\u003cspan address=\"https://chwtraining.org/15-community-health-worker-job-titles-and-different-roles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health. 2015;13:95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel AR, Nowalk MP. Expanding immunization coverage in rural India: A review of evidence for the role of community health workers. Vaccine. 2010;28(3):604\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoyce MR, Katz R. Community Health Workers and Pandemic Preparedness: Current and Prospective Roles. Front Public Health. 2019;7:62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2019.00062\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2019.00062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteenbeek A, Gallant A, MacDonald NE, Curran J, Graham JE. Nova Scotia Strong: why communities joined to embrace COVID-19 public health measures. Can J Public Health. 2022;113(Suppl 1):4\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/ACM.00000000000000388\u003c/span\u003e\u003cspan address=\"10.1097/ACM.00000000000000388\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualizing access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/14759276-12-18\u003c/span\u003e\u003cspan address=\"10.1186/14759276-12-18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpradley J. Participant observation. Reissued ed. Long Grove, IL: Waveland Press; 2016. xi, 195 p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChabot C, Shoveller J. Observations and Interviews. In: Shoveller J, Chabot C, Oliffe J, Gilbert M, editors. Designing and conducting gender, sex, and health research. Thousand Oaks, CA: SAGE Publications; 2011. p.105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKallio H, Pietil\u0026auml; AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954\u0026ndash;65. 10.111/jan.13031.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrancis JJ, Johnston M, Robertson C, Glidewell L, Entwhistle V, Eccles MP, Grimshaw JM. What is an adequate sample size? Operationalising data saturation for theory-driven interview studies. Psychol Health. 2010;25(10):1229\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/08870440903194015\u003c/span\u003e\u003cspan address=\"10.1080/08870440903194015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893\u0026ndash;907. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11135-017-0574-8\u003c/span\u003e\u003cspan address=\"10.1007/s11135-017-0574-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLumivero. NVivo [computer software]. Version 14.2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.lumivero.com\u003c/span\u003e\u003cspan address=\"https://www.lumivero.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElo S, Kyngas H. The qualitative content analysis process. J Clin Nurs. 2008;62(1):107\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandelowski M. Qualitative analysis: what it is and how to begin? Res Nurs Health. 2005;18:371\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque\u0026rsquo;s conceptual framework: a scoping review. Int J Equity Health. 2021;20:116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12939-021-01416-3\u003c/span\u003e\u003cspan address=\"10.1186/s12939-021-01416-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevesque JF, Sutherland K. Combining patient, clinical and system perspectives in assessing performance in healthcare: an integrated measurement framework. BMC Health Serv Res. 2020;20:23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-019-4807-5\u003c/span\u003e\u003cspan address=\"10.1186/s12913-019-4807-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlanagan J, Beck CT. Polit and Beck\u0026rsquo;s Nursing Research: Generating and Assessing Evidence for Nursing Practice. 12th ed. New York: Wolters Kluwer Health, Lippincott, Williams \u0026amp; Wilkins; 2025. [e-book].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLehmann U, Sanders D, Impact on Health Outcomes of Using Community Health Workers. Community Health Workers: What Do We Know about Them. The State of the Evidence on Programmes, Activities, Costs and. Geneva: World Health Organization; 2007. [Internet]. [cited 2025 Nov 21]. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf\u003c/span\u003e\u003cspan address=\"https://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant M, Wilford A, Haskins L, Phakathi S, Mntambo N, Horwood CM. Trust of community health workers influences the acceptance of community- based maternal and child health services. Afr J Prim Health Care Fam Med. 2017;9(1):e1-e7. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf\u003c/span\u003e\u003cspan address=\"https://chwcentral.org/wp-content/uploads/2013/07/Community-Health-Workers-What-do-we-know-about-them.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBashyal LK. Payment and Motivation: Female Community Health Volunteers in Nepal. Dhaulagiri J Sociol Anthropol. 2023;17(1):39\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3126/dsaj.v17i01.61143\u003c/span\u003e\u003cspan address=\"10.3126/dsaj.v17i01.61143\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJigssa HA, Desta BF, Tilahun HA, McCutcheon J, Berman P. Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions. Hum Resour Health. 2018;16:57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12960-018-0319-3\u003c/span\u003e\u003cspan address=\"10.1186/s12960-018-0319-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakasugi T, Lee ACK. Why do community health workers volunteer? A qualitative study in Kenya. Public Health. 2012;126(10):839\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.puhe.2012.06.005\u003c/span\u003e\u003cspan address=\"10.1016/j.puhe.2012.06.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajid U, Zahid M, Harold K, Zain S, Sood T. Challenges in the sociocultural milieu of South Asia: A systematic review of community health workers. Rural Remote Health. 2021;21(4): 1\u0026ndash;13. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://search.informit.org\u003c/span\u003e\u003cspan address=\"https://search.informit.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e/doi/10.3316/informit.299463446498108\u003c/span\u003e\u003cspan address=\"/doi/10.3316/informit.299463446498108\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOosterveer MT, Young KT. Primary health care accessibility challenges in remote Indigenous communities in Canada\u0026rsquo;s North. Int J Circumpolar Health. 2015;74(1):29576. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3402/ijch.v74.29576\u003c/span\u003e\u003cspan address=\"10.3402/ijch.v74.29576\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBillings J, Ching BCF, Gkofa V, Greene T, Bloomfield J. Experiences of frontline healthcare workers and their views about support during COVID-19 and previous pandemics: a systematic review and qualitative meta-synthesis. BMC Health Serv Res. 2021;21:923. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-021-06917-z\u003c/span\u003e\u003cspan address=\"10.1186/s12913-021-06917-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community Health Workers, healthcare service delivery, Lévesque conceptual framework, health outcomes, qualitative descriptive research","lastPublishedDoi":"10.21203/rs.3.rs-9141682/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9141682/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study examines the experiences of community health workers (CHWs) providing care in Delhi India during and after the COVID-19 pandemic, and how their roles were perceived and accepted by beneficiaries and community leaders. Although CHWs are critical to healthcare delivery, limited evidence describes how they navigate role expectations, community dynamics, and system complexities to better improve health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative descriptive study using semi-structured interviews and field observations with 12 CHWs, five community members, and four community leaders (March–May 2025). The Lévesque conceptual framework guided data collection and analysis. Data were analyzed using content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross the supply-side domains (approachability, acceptability, availability/accommodation, affordability, and appropriateness), three key categories emerged: (1) trust and respect, (2) professional values, and (3) norms, culture, and family. For the demand-side domains (ability to perceive, seek, reach, pay, and engage), one key category, community needs was identified. COVID-19 impacts and quality-of-care concerns were evident across all domains.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings highlight the need for future research on sociocultural influences shaping CHWs’ professional roles, the sustainability of incentive-based remuneration, and the long-term implications of digital technologies adopted during crises such as COVID-19.\u003c/p\u003e","manuscriptTitle":"A Qualitative Exploration of Community Health Workers’ Roles and Motivations in Delivering Care During and After the COVID-19 Pandemic: Experiences and Community Perceptions in Rural and Urban Delhi, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 14:37:37","doi":"10.21203/rs.3.rs-9141682/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-14T02:51:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T10:56:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T02:19:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325534751531875090916710456532708084298","date":"2026-04-29T02:10:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256607021761665176248942510944843762208","date":"2026-04-22T05:01:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T16:26:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59900032403559533755259082585599157902","date":"2026-04-18T15:52:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T06:54:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T07:21:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-18T05:39:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-18T05:39:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-03-16T20:30:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05df205a-5277-4a3e-98d2-68fb7ec3c7c8","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-14T02:51:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T10:56:25+00:00","index":74,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T02:19:12+00:00","index":73,"fulltext":""},{"type":"reviewerAgreed","content":"325534751531875090916710456532708084298","date":"2026-04-29T02:10:17+00:00","index":72,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T21:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 14:37:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9141682","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9141682","identity":"rs-9141682","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}